20-3D

Treatment Program Client Rights

As a participant in CCA's treatment program, you are guaranteed certain rights. It is imperative that you
know and understand these rights. As a program participant, have the right to:

1. Be treated with dignity and respect.

2. Know all the rules and policies you will be expected to observe.
3. Be informed of your rights verbally and in writing.
4. Give informed consent acknowledging your permission for us to provide treatment.
5. Have all records and other information concerning your participation in the program held in
confidence in accordance with Federal regulations.
6. Know the limits of confidentiality and the situations in which staff is legally required to disclose
your treatment information.
7. Receive complete and accurate information about your treatment plan, goals, methods,
potential risks, benefits, and progress.
8. Be free from participating in audio or video recording with your express consent.
9. File a grievance if your rights have been denied or limited.

By signing below, I ______________________________ indicate that I understand my rights as a

participant in CCA's treatment program.

__________________________________________ ______________________________
Pt. Signature Date

______________________________________________ ________________________________
Counselor Signature RudolphKolderMA Date

Proprietary Information – Not for Distribution – Copyrighted – Property of CCA 6/10/15