FERD & GLADYS ALPERT JEWISH FAMILY SERVICE Of Palm Beach County, Inc.
Client Rights and Responsibilities
And Informed Consent to Receive Services
I have chosen to receive services from Ferd & Gladys Alpert Jewish Family Service of Palm Beach County, Inc., hereafter referred to as Alpert JFS. My choice has been voluntary and I understand that I may withdraw my participation at any time.
I understand that records and information collected about me will be held or released in accordance with state laws regarding confidentiality of such records and information.
I understand that state and local laws require that my caseworker or therapist report all cases of actual or suspected abuse or neglect of minors or vulnerable adults.
I understand that the state and local laws require that my caseworker or therapist report all cases in which there exists a danger to self or others. I acknowledge that this could occur.
I understand that there may be other circumstances in which the law requires confidential information to be disclosed.
I understand that I may be eligible for a subsidized rate based upon demonstrated need and available agency resources.
I understand that if I am consenting to receive services for which there is a fee, I am responsible for payment of all fees agreed upon.
I understand that I have among my rights, the following:
The right to integrated, coordinated, and carefully monitored services.
The right to confidentiality under federal and state laws relating to the receipt of services
The right to humane care and protection from harm, abuse, or neglect.
The right to make an informed decision about whether to accept or refuse treatment, unless those rights are limited by law or court order.
The right to refuse to participate in clinical studies or research without written permission
The right to be actively involved in the development of an individualized plan of services, designed to meet my specific needs.
The right to understand the consequences of different services and how the organization can help me achieve these choices.
The right to be referred back to my managed care provider for information about services.
The right to review my record, as outlined within state statutes, and in accordance with the policies of Alpert JFCS.
The right to have my complaints and problems heard and responded to within the guidelines of the grievance procedures of Alpert JFCS. Grievance forms are available at the reception desk and should be directed to
The right to have the contents of these rights and the contents of the Service Plan explained in a language that is understandable, including sign language, verbal, written, or any other manner.
The right to have information about client rights and the contents of the Service Plan made available to the parents / legal guardian of a minor / mentally disabled individual as well as to the individual himself / herself.
I understand that I can revoke my consent for the agreed upon services at any time, except to the extent that treatment has already been rendered or that action has already been taken in reliance on this consent, and that if I do not revoke this consent, it will expire automatically when treatment ceases.