• Enrollment Form

  • Format: (000) 000-0000.
  • Court Ordered Legal Guardian*
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  • Format: (000) 000-0000.
  • Transportation Type*
  • LifeSpan Waiver Funding*
  • Pathways to Employment Funding*
  • Do you have the following Support Documents? (If yes, documents must be provided)*
  • Do you have any known allergies?*
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  • Release of Information

  • Date of Birth*
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    2 digit month, 2 digit day, 4 digit year
  • I authorize Ability Focused Professional Services, LLC. to release and/or obtain relevant information from the following entities:*

  • Client Service Agreement

  • •Client Rights:
    If you receive services, you have a right to the following:
    • Receive services from the provider of your choice
    • Person centered planning
    • File a grievance against provisions of services
    • Receive a fair review and hearing of your grievance

    Client Responsibilities, and Expectations:
    • Follow-through with all commitments.
    • Actively participate in all scheduled program session maintaining a 90% participation eligibility requirement. 
    • Participate in the identification of their skills, interests, and abilities.
    • Participate in the identification of their person centered service goals.
    • Participate in all job development activities. (as applicable)
    • Look for job leads. (as applicable)
    • Prepare for noted vocational or community planned activities.
    • Look for community resources which will aid your success (such as planning for and utilizing agreed upon method of transportation).
    • Identify any needs or accommodations you may need to support your vocational/ community success.
    • Strive to meet activity and service expectations.
    • Become familiar with any related policies and procedures.
    • Participate in your performance appraisal and improve performance, as needed. (as applicable)
    • Communicate right away with their Support Specialist about problems that arise.
    • Maintain acceptable attendance at work, or your community commitments.
    • Complete and submit community participation activity sheets to the program office. (as applicable)

    •Participate in HCBS Day services typically scheduled in (4) four hour timeframes. Typically 8am-12pm/1pm-5pm. Agency travel limits for services are within 30 minutes from the clients home address on their PCP.

     •It is my responsibility to be ontime, and engaged in service within 15minutes of my DSP arrival time, or a may forfeit service that day at the discrection of the agency.

    •It is my responsibility to provide at least three (3) weeks' advance notice for planned absences whenever possible.
    •I am responsible for maintaining a minimum attendance rate of ninety percent (90%) over a rolling ninety (90) day period.
    •I am expected to participate in scheduled services consistently and communicate any inability to attend as soon as possible. Three (3) unexcused absences, tardiness within a rolling ninety (90) day period may result in a temporary suspension of services.
    If services are suspended due to attendance concerns, a team meeting will be scheduled to review service expectations, identify barriers to participation, and determine the steps necessary for services to resume.

     

    AFPS Support Specialist Responsibilities
    The AFPS Support Specialist agrees to assist you in:
    • Identifying your skills, interests, and abilities.
    • Identifying your person centered service goals.
    • Preparing for interviews (such as role play, simulation, proper dress, question/answers, transportation). (as applicable)
    • Locating and accessing resources within the community (employers, transportation, community information, community events). (as applicable)
    • Identifying job leads. (as applicable)
    • Identifying supports and accommodations which will enable you to perform to the best of your ability.
    • Assist you in negotiating terms of employment. (as applicable)
    • Assist in facilitating your relationship with your supervisor and co-workers.
    • Understanding your activities policies and procedures.

    Your AFPS Support Specialist will also:
    • Assist in you scheduling an SBI background check. (as applicable)
    • Be an active partner in your development activities.
    • Support you in training, or activities. (as applicable)
    • Provide feedback and suggest alternative methods of meeting required expectations.
    • Be available to you and your employer, as needed and requested. (as applicable)
    • Maintain communication with you and your designated point of contacts.

    We agree that meeting these terms is a condition of our successful working relationship.

  • CLIENT RIGHTS AND RESPONSIBILITIES

  • The following statements have been organized in a manner to which client rights and responsibilities are explained in general terms and in other terms regarding specific services. Bysigning this agreement, I am testifying to AFPS Client Services that my opinions do not differand that I have clarified any details that were unclear to me. This document may be referred tothroughout services.

    Client Rights Before or After Placement
    1. To review my case records at any time by notifying the DSP with whom Iam working.
    2. To know about AFPS Client Services as an organization including:
    • The types of services offered
    • The eligibility criteria
    • Any policies and procedures that affect the services I may receive
    • The approximate waitlist for services
    • Previous performance outcomes
    3. To participate in establishing all plans and goals for the services I am receiving, includingexpressing any opinions or desires I have about all services I wish to receive.
    4. To invite anyone, I wish to all meetings held regarding the services I am receiving.
    5. To refuse services. I can then expect appropriate staff to explain to me the consequencesof that decision.
    6. To request to work with a certain DSP and to have that request reviewed by the Director.
    7. To complete confidentiality. I understand that staff from AFPS Client Services cannotrelease any confidential information to any outside sources without written permission fromme or my legal guardian.
    8. To appeal a decision that is made that I do not agree with by contacting the Director and/ormy DVR Counselor. I agree to talk about the disagreement initially with my DSP, but if anagreement cannot be reached, I also have the right to contact DVR Counselor or DDDS CaseManager regarding unhappiness with services.

    Client Responsibilities Before or After Placement
    1. To keep my DSP informed of any upcoming events that would require long-term absencefrom my job or job development activities, such as vacations orsurgeries.Rev.2023 29
    2. To disclose any criminal record or conviction of a crime other than minor traffic violations toAFPS. I understand that not disclosing this information to an employer and the with whomI'm working may disqualify me for employment and/or further Client Services.
    3. To make known any potential risks to my health and/or safety that may impact my ability toreceive services from AFPS Client Services. Risks are considered to be exposure to apredictable event or environment that could result in serious physical or psychological injuryto me or someone else.
    4. To be truthful with my DSP in order to receive the best possible services during jobdevelopment and after job placement.
    5. To communicate with my DSP continuously throughout services. I am depended upon tokeep my DSP updated on any happenings during job development and after placement. For example, if an employer calls me for an interview or if I am being mistreated at work, I willnotify the DSP immediately. I also agree to speak with my DSP before acting on decisionsthat I have made to determine consequences of that decision and the best possible outcome.

    Client Rights and Responsibilities Specific to Job Development
    1. I agree to actively participate in my job search. I will assist the DSP in establishing goalstowards successful employment and follow my DSP’s guidance in locating a job that suitsmy employment desires and needs. I also will keep my DSP fully informed of where andwhen I have job searched on my own inthe community.
    2. I will notify my DSP of any occurrence related to finding a job including, but not limited to,calls from potential employers, upcoming interviews, or changing employment desires.
    3. I have the right to accept or not accept any employment that is offered to me and can expectmy DSP to discuss the outcome of that decision with me.

    General Understandings (After Placement)
    1. I understand there might be several AFPS staff working with me until I am able to do my jobindependently. Therefore, I agree to accept instructions from any Job Coach during jobcoaching.
    2. I understand that once the DSP, my employer, and I agree that AFPS Client Services support can fade, a Job Coach will be available to spot check and monitor my work.
    3. I understand that my employer and AFPS staff may regularly review my work performance.
    4. It is the responsibility of the employer to follow all labor laws, including minimum wage,personnel records, family leave, etc.Rev.2023 30

    By signing below, I acknowledged that I have reviewed and understand my rights andresponsibilities as a person receiving services from AFPS.

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