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Acknowledgement - Signing a Contract

Acknowledgement of Receipt of Grievance Policy and Privacy Practices / HIPPA Policies 

Please note that children under 18 must be accompanied by a legal guardian. Adults with guardians must obtain written consent from the legal guardian prior to being served. (Please provide a copy of guardianship papers for Adults).

Is this your legal name?
Legal Guardian?
Legal Guardian Relationship

Association with AWS in no way represents abridgment of your rights as guaranteed by our own
Constitution. To the contrary, we hope to extend a family like consideration to all the people that we 
support. All of our staff, the people we serve, their family and friends deserve our respect and 
support. We expect to project an atmosphere of mutual trust and consideration. Below are listed 
some of the rights that are guaranteed to all citizens of our country. These rights include but are not 
limited to: 


  1. The right to dignity, human care and freedom from mental and physical abuse, neglect and exploitation.

  2. The right to physical safety and health.

  3. The right to humane and adequate care and treatment

  4. The right to self- determination, freedom of choice and enjoyment of every privilege to the fullest capacity possible.

  5. The right to be free of discomfort, distress and deprivation.

  6. The right to live in the least restrictive setting possible.

  7. The right to have adequate resources and services provided in the least restrictive setting.

  8. The right to have available a quality program of supervision and support.

  9. The right to have a barrier fee environment to the maximum extent possible.

  10. The right to be treated in as fashion appropriate to one’s age and customs and practices of ones’ folk culture.

  11. The right to undergo normal development experiences even when they mail entail an element of risk.

  12. The right to engage in activities and social interactions with other citizens in the community.

  13. The right to be addressed in a fashion appropriate to ones’ chronological age.

  14. The right to engage in a social and sexual activity appropriate to chronological age and social maturity level.

  15. The right to physical exercise and leisure time activity.

  16. The right to freedom of worship.

  17. The right to live in the most homelike atmosphere possible.

  18. The right to vote unless otherwise adjudicated.

  19. The right to receive assistance in citizenship training and voter registration.

  20. The right to communicate and receive correspondence.

  21. The right to send and receive sealed mail and have access to writing material, postage and staff assistance when necessary.

  22. The right to personal privacy, for at least periods of time, unless determined inappropriate by the treatment team.

  23. The right to freedom of association.

  24. The right to be free from cruel and unusual punishment.

  25. The right not to be exposed to public view by photograph or other means without proper consent.

  26. The right to prompt and appropriate medical care and treatment.

  27. The right to possess and dispose of personal property.

  28. The right to refuse or terminate services, except when services are required by court order.

  29. The right to not be subjected to experimental research without your and/or your guardian's expressed and informed consent. If consent is given, either you or your guardian may withdraw at any time.

  30. The right to keep and manage his/her own funds unless requested otherwise.

  31. The right to have access to proper supervision and guidance.

  32. The right to opportunities that enable you to mature physically, emotionally, intellectually, socially and vocationally.

  33. The right to have your record and all information about you kept confidential except where state law or court order requires that information to be released.

  34. The right to an individualized Person Centered Plan setting forth a program to maximize ones’ capabilities.

  35. The right to marry, procreate and raise children.

  36. The right to receive age- appropriate treatment for a diagnosis.

  37. The right to be free from unnecessary medication.

  38. The right to not have medication used for punishments, discipline or staff convenience.

  39. The right to have an individualized written discharge plan containing recommendations for further services designed to live normally as possible.

  40. The Right to contact and consult with, at his/her own expense and at no cot to the facility, legal counsel, private physicians and private MHDD/SA professional of his/her choice.

  41. The right to live as normally as possible while receiving care and treatment.

  42. The right to receive necessary treatment for a prevention of physical ailments based upon the condition and projected length of stay.

  43. The right to contact and consult with a consumer advocate.

  44. Adult consumers shall have access to telephones in private areas, when requested by the consumer.

  45. The right to a quiet atmosphere for uninterrupted sleep during scheduled sleeping hours.

  46. The right to decorate his/her room, with respect for the physical structure of the facility. Any restrictions, shall be carried out in accordance with governing body policy.

  47. The right to adequate toilets, lavatory and bath facilities equipped for use by a consumer with a mobility impairment shall be available.

  48. The right to bathtubs, showers and toilets that ensure privacy.

  49. The right for personal health, hygiene and grooming care. Such rights shall include, opportunity for a shower/bath daily, or more as needed; opportunity to shave daily, opportunity to obtain the services of a barber/beautician, provisions of linens and towels, toilet paper and soap, toothbrush, sanitary napkins shaving cream and utensils.

I have reviewed a copy of the Notification of Participant Rights.
The above information has been explained to me.

Thanks for submitting!

> Refer A Patient Or Loved One


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