Form #24   PATIENT BILL OF RIGHTS AND CONSENT TO TREAT

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Client Name:                                           Date:                             Client Social Security Number:

When you receive services for mental health, alcoholism, drug abuse, or a developmental
disability, as an impatient or outpatient, you have rights under Wisconsin Statute 51.61.
Some of these are . . .

TREATMENT AND RELATED RIGHTS:
*    To be free from having unreasonable arbitrary decisions made about you.
*    To receive prompt and adequate treatment.
*    To refuse any treatment.
*    To give informed consent to treatment.

COMMUNICATION AND PRIVACY RIGHTS:
*    To refuse to be filmed or taped without your consent
*    To have access to your treatment record after discharge or during treatment.

RIGHT OF ACCESS TO COURTS:
*    To bring a legal action for damages against those who violate your rights.

YOUR RIGHT TO COMPLAINT:
    If you feel that your rights have been violated, you have the right to a grievance
procedure under HSS 94, Patient Rights.  Our agency has a grievance process and a
Client's Rights Specialist through which you may file your complaint.  Grievances must
be filed in writing within 45 days of the incident or issue.  The staff will supply you with
a copy of the Grievance Procedure upon request.  You may at the end of the grievance
or at any time during it choose to take the matter to court.

I have reviewed my rights and treatment plan with my therapist and, having been
provided due consideration, I give my consent and authorization for treatment/
psychological services.  With my signature, I am verifying that I have been informed
of the benefits, risks, and possible side effects as well as financial costs of treatment,
alternative treatment modes, and the consequences of not receiving treatment.

*    You may revoke your consent in writing at any time.  This consent is valid for one
year from the date below.

_________________________________________________________
Client/Guardian Signature:                                                          Date:

_________________________________________________________
Therapist's Signature:                                                                  Date:

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                            A STATE CERTIFIED MENTAL HEALTH CLINIC