Restoration Family Services Forms

I have read or had explained to me information concerning consumer rights as presented by Restoration Family Services, Inc. (RFS).

I further acknowledge that I have been presented a copy of the Consumer Handbook, which contains rules each employee is expected to follow and possible penalties for their violation.
● Information regarding the disclosure of confidential information
● How to obtain a copy of the consumer’s treatment/habilitation plan
● Grievance procedure including the appropriate staff person to contact
● Information regarding policy for discharge from services
● Information regarding policy for search and seizure
● Fees and Collection Practices
● Right to contact Disability Rights of North Carolina (formerly GACPD) at 919-856-2195
● Permitted restrictive intervention, protective device will not be used
● The purpose, goals, and reinforcement structure of any behavior management system used by the RFS staff has been explained
● Information that the legally responsible person of a minor or an incompetent consumer has been informed that he/she may request a notification after each use of a restrictive intervention and any request to be notified is documented (if restrictive intervention are permitted by RFS staff)
● I have been informed that a legally competent adult consumer may designate an individual to be notified after any use of a restrictive intervention or rights restriction and, that the notification will be documented

My signature acknowledges that I have read, had training, and understand the policy on Consumer Rights.
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Stand: 12/23/2021