California Client Services Agreement
PARENT-CHILD ASSISTANCE PROGRAM (PCAP)
Client SERVICE AGREEMENT
Thank you for choosing to participate in the Parent-Child Assistance Program (PCAP). The purpose of the program is to offer 3 years of support and services that will help women and their families become healthy and alcohol and drug free.
While you are in PCAP, your case manager will be in touch with you many times a month, including home visits. She will ask about what kinds of goals and needs you have, and develop a plan of care and services that will meet your needs and help you reach your goals. She will review this plan with you every few months. During the program, your case manager will help link you with the community services that are just right for you. Based on your needs, she will help you with supplies, activities, and incentives while you are in the program. If you sign release forms to coordinate services with other providers, your case manager will talk with those other service providers (such as DSHS, probation, medical) when she needs to.
Your case manager will work with you for 3 years. Here is what you can expect:
She’ll always be truthful with you. She won’t lie to you, or for you.
She won’t meet with you if you are high or carrying alcohol or drugs.
She will be with you through ups and downs. There may be times you are upset with her. It’s okay to disagree, but it is important to keep communication open.
She has other clients and there may be times when she has to cancel an appointment with you because of someone else’s emergency.
Her role is not to always respond to your crises, but to help you move toward reaching your goals.
She’ll be on time, and if you need to cancel you should call her in advance.
She will let you know ahead of time if she must make a report to Child Protective Services.
She will have a 3-year working relationship with you, not a 3-year friendship.
You’ll get as much out of the program as you put into it.
We will evaluate PCAP to know if the program helps women become healthy and drug free. We would like to interview you when you start PCAP and again when you leave the program. We will ask you questions about your family, your use of drugs and alcohol, your pregnancy history, and your arrest history. The interviews take about 1 hour. Some questions are very personal, such as "Have you worked as a prostitute in the last 3 years, for either drugs or money?" You can skip any question you don’t want to answer.
All evaluation forms will use a code number, not your name. Your name and code number will be kept separate from evaluation information. All evaluation information will be kept in locked files. Information we learn from you won’t be put into any medical record or given to your other service providers, unless you give us permission in writing. There are some exceptions to the promise of privacy. If you tell us that you may harm yourself or others, we will report it to a mental health worker or the police. If we become aware of child abuse or neglect, we will report it to child protective services. If you need medical help, we may report medical information. If the government audits us, they may see your information.
As a client, you have the right to be treated with respect and dignity. You will receive care which does not discriminate against you, and is sensitive to your gender, race, national origin, age, disability, sexual orientation, and spiritual beliefs. You will not be abused.
In turn, you are responsible for being respectful of the rights of others. You may not bring or use illegal drugs, alcohol, or weapons on PCAP property or in PCAP vehicles. You are expected to not use language and behavior that is threatening to yourself, others, or property.
If you have a complaint that you can not work out with your case manager, you can call the PCAP clinical supervisor to discuss the problem. You don’t have to be in PCAP if you don’t want to, and you may leave at any time, unless you were ordered by CPS or the courts. If you would like to leave the program, you can call the PCAP clinical supervisor, Janet Burtt, MFT at (562) 923-4545 ext. 2231.
____________________________________ _________________
Signature of Participant Date
____________________________________ ___________________
Signature of Clinical Supervisor Date
Copies to: Participant 8.19.08
Client file
| File Type | application/msword |
| File Title | COMMUNITY PSYCHIATRIC CLINIC |
| Author | Trial User |
| Last Modified By | MeyyuVi |
| File Modified | 2010-02-02 |
| File Created | 2010-02-02 |