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Telemedicine PACKET Adult / Child

(To be explained to staff and signed by Individual, then FILED IN CHART

Individual will be given “Individual Orientation” at intake)


(Provide Client Copy)

When you receive services in a community mental health, mental retardation, and/or substance abuse program, your rights are protected by Rules and Regulations contained in Chapter 290-4-9. A full copy of the Rules is available to you at the program where you are served. Below is a simplified outline of those rights. The Rules and Regulations describe any limitation to these rights and other provisions, which may apply and should be consulted when there is a dispute or question regarding any of these rights.


Your rights include:

● The right to an interpreter if you do not speak English or are hearing impaired.

● The right to receive services that respect your dignity, and protect your health and safety

● The right to know the names and positions of all those involved in services planning and implementation process

● The rights to be informed of the benefits and risk of your treatment.

● The rights to participate in planning your own program.

● The right to refuse service, unless a physician or licensed psychologist feels that refusal would be unsafe for you or others.

● The right to receive care suited to your needs.

● The right to prompt and confidential services even if you are unable to pay.

● The right to review and obtain copies of your records, unless the physician or other authorized staff feels it is not in your best interest.

● The right to exercise all civil, political, personal and property rights to which you are entitled as citizen.

● The right to be free of physical or verbal abuse.

● The right to converse privately, to have reasonable access to a telephone, to receive/send mail, to have visitors and to retain your personal effects, clothing and money, except if denial is necessary for treatment/rehabilitation-documented by physician/licensed psychologist.

● The right to have advance directives, such as a living will, health care proxy, or durable power of attorney that clearly states your treatment wishes.

● The right to file a complaint if you think any of these rights have been restricted or denied.


If you want to know more about your rights, a full copy of the Regulations is available to you on report. A summary of the Individual Rights Complaint Process is also available.


The Individual/Legal Representative has had an opportunity to read, or have read to him/her, the above form and ask questions regarding the data contained therein and has in this staff member’s presence.


PROBLEM BEHAVIORS: These are behaviors I sometimes show, especially when I’m stressed:
TRIGGERS: When these things happen, I am more likely to feel unsafe and upset:
WARNING SIGNS: These are things other people may notice me doing if I begin to lose control:
INTERVENTIONS: These are things that might help me calm down and keep myself safe when I’m feeling upset: (Check off what you know works; star things you might like to try in the future)
THINGS THAT MAKE IT WORSE: These are things that do NOT help me calm down or stay safe:
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