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In addition, you have the following rights that are protected by laws which govern all mental health services. ) /E (As a consumer of 51Թ services, you shall retain the same basic legal and civil rights as other citizens, unless a specific right has been lawfully curtailed or denied through court action or other appropriate measures as outlined below. In addition, you have the following rights that are protected by laws which govern all mental health services. ) /Pg 7 0 R /K [10] >> endobj 62 0 obj << /Type /StructElem /S /P /E ( ) /Pg 7 0 R /K [8] >> endobj 63 0 obj << /Type /StructElem /S /H1 /T (These rights cannot be denied under any circumstances: ) /E (These rights cannot be denied under any circumstances: ) /Pg 7 0 R /K [9] >> endobj 64 0 obj << /Type /StructElem /S /H1 /T (1. I have the right to humane and appropriate care and treatment in the least restrictive setting ) /E (1. I have the right to humane and appropriate care and treatment in the least restrictive setting ) /Pg 7 0 R /K [27] >> endobj 65 0 obj << /Type /StructElem /S /H1 /T (with as much freedom as safety permits, devoid of physical, sexual or emotional abuse, ability to pay, financial exploitation, retaliation, humiliation or any form of neglect. ) /E (with as much freedom as safety permits, devoid of physical, sexual or emotional abuse, ability to pay, financial exploitation, retaliation, humiliation or any form of neglect. ) /Pg 7 0 R /K [28] >> endobj 66 0 obj << /Type /StructElem /S /H1 /T (2. I have the right to be provided with mental health services without discrimination because of ) /E (2. I have the right to be provided with mental health services without discrimination because of ) /Pg 7 0 R /K [11] >> endobj 67 0 obj << /Type /StructElem /S /H1 /T (race, color, sex, sexual orientation, gender identity, creed, religion, age or national origin. ) /E (race, color, sex, sexual orientation, gender identity, creed, religion, age or national origin. ) /Pg 7 0 R /K [12] >> endobj 68 0 obj << /Type /StructElem /S /H1 /T (3. I have the right to receive services in an environment which is physically safe and sanitary, ) /E (3. I have the right to receive services in an environment which is physically safe and sanitary, ) /Pg 7 0 R /K [13] >> endobj 69 0 obj << /Type /StructElem /S /H1 /T (and which will contribute to my recovery. ) /E (and which will contribute to my recovery. ) /Pg 7 0 R /K [14] >> endobj 70 0 obj << /Type /StructElem /S /H1 /T (4. I have the right to address concerns regarding staff assignments, and to request changes in ) /E (4. I have the right to address concerns regarding staff assignments, and to request changes in ) /Pg 7 0 R /K [15] >> endobj 71 0 obj << /Type /StructElem /S /H1 /T (staff if I believe my needs are not being met. ) /E (staff if I believe my needs are not being met. ) /Pg 7 0 R /K [16] >> endobj 72 0 obj << /Type /StructElem /S /H1 /T (5. I have the right to grieve any concerns I have about my treatment including the quality of ) /E (5. I have the right to grieve any concerns I have about my treatment including the quality of ) /Pg 7 0 R /K [17] >> endobj 73 0 obj << /Type /StructElem /S /H1 /T (services provided or decisions that impact the amount of services I receive, including the decision to be discharged from services. I will not be subject to any manner of discrimination, penalty, sanction or restriction for filing a complaint and/or exercising my grievance rights. ) /E (services provided or decisions that impact the amount of services I receive, including the decision to be discharged from services. I will not be subject to any manner of discrimination, penalty, sanction or restriction for filing a complaint and/or exercising my grievance rights. ) /Pg 7 0 R /K [18] >> endobj 74 0 obj << /Type /StructElem /S /H1 /T (6. I cannot be asked to waive any of my rights as a condition of being treated. However, I may ) /E (6. I cannot be asked to waive any of my rights as a condition of being treated. However, I may ) /Pg 7 0 R /K [19] >> endobj 75 0 obj << /Type /StructElem /S /H1 /T (agree not to exercise a specific right in the interests of my treatment plan. ) /E (agree not to exercise a specific right in the interests of my treatment plan. ) /Pg 7 0 R /K [20] >> endobj 76 0 obj << /Type /StructElem /S /H1 /T (7. Under certain circumstances, including in the interests of program safety, my belongings may ) /E (7. Under certain circumstances, including in the interests of program safety, my belongings may ) /Pg 7 0 R /K [21] >> endobj 77 0 obj << /Type /StructElem /S /H1 /T (be searched. ) /E (be searched. ) /Pg 7 0 R /K [22] >> endobj 78 0 obj << /Type /StructElem /S /H1 /T (8. If I attempt to injure myself or another person, any physical restraint imposed on me must be ) /E (8. If I attempt to injure myself or another person, any physical restraint imposed on me must be ) /Pg 7 0 R /K [23] >> endobj 79 0 obj << /Type /StructElem /S /H1 /T (limited to that which is absolutely necessary to handle the situation. ) /E (limited to that which is absolutely necessary to handle the situation. ) /Pg 7 0 R /K [24] >> endobj 80 0 obj << /Type /StructElem /S /H1 /T (9. If my treatment requires a 51Թ psychiatrist to prescribe medication, I will be given information about the medication and I will be required to give my written consent for ) /E (9. If my treatment requires a 51Թ psychiatrist to prescribe medication, I will be given information about the medication and I will be required to give my written consent for ) /Pg 7 0 R /K [25 26] >> endobj 81 0 obj << /Type /StructElem /S /P /E (Clients Rights: All programs Revised: 05/2020 ) /Pg 7 0 R /K [1] >> endobj 82 0 obj << /Type /StructElem /S /P /E (Page 1 of 5 ) /Pg 7 0 R /K [4] >> endobj 83 0 obj << /Type /StructElem /S /P /E (Attachment A ) /Pg 8 0 R /K [2] >> endobj 84 0 obj << /Type /StructElem /S /P /E <506F6C69637920232037203130303220436F6E73756D65729073204C6567616C20616E6420436976696C2052696768747320> /Pg 8 0 R /K [3] >> endobj 85 0 obj << /Type /StructElem /S /H1 /T (administration of the medication. \(The guardian or conservator of non-emancipated minors must also consent to treatment for those individuals.\) If I or my guardian/conservator, as appropriate, decline to give written consent, the psychiatrist will collaborate with me about use of medications and alternate methods of treatment. ) /E (administration of the medication. \(The guardian or conservator of non-emancipated minors must also consent to treatment for those individuals.\) If I or my guardian/conservator, as appropriate, decline to give written consent, the psychiatrist will collaborate with me about use of medications and alternate methods of treatment. ) /Pg 8 0 R /K [11] >> endobj 86 0 obj << /Type /StructElem /S /H1 /T (10. 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My medical record is confidential and cannot be released to people who are not involved in ) /E (1. My medical record is confidential and cannot be released to people who are not involved in ) /Pg 8 0 R /K [5] >> endobj 90 0 obj << /Type /StructElem /S /H1 /T (providing services to me. Exceptions to this are as follows: ) /E (providing services to me. Exceptions to this are as follows: ) /Pg 8 0 R /K [6] >> endobj 91 0 obj << /Type /StructElem /S /H1 /T (a. Under court order. b. When expressed written consent is given by me or my guardian/conservator. c. When I am at imminent risk to myself or others, or I have disclosed abuse toward a ) /E (a. Under court order. b. When expressed written consent is given by me or my guardian/conservator. c. When I am at imminent risk to myself or others, or I have disclosed abuse toward a ) /Pg 8 0 R /K [7] >> endobj 92 0 obj << /Type /StructElem /S /H1 /T (child, dependent or elderly person. In these situations, the appropriate legal authority will be contacted, and a report will be made. ) /E (child, dependent or elderly person. In these situations, the appropriate legal authority will be contacted, and a report will be made. ) /Pg 8 0 R /K [8] >> endobj 93 0 obj << /Type /StructElem /S /H1 /T (d. To a physician in the case of a medical emergency. e. Auditors from regulatory agencies. ) /E (d. To a physician in the case of a medical emergency. e. Auditors from regulatory agencies. ) /Pg 8 0 R /K [9] >> endobj 94 0 obj << /Type /StructElem /S /H1 /T (2. I have the right to request access to my record. 3. I have the right to request an amendment to my record. 4. I have the right to request an accounting of certain disclosures of information in my record. 5. I have the right to request a restriction for use and disclosure of my record. ) /E (2. I have the right to request access to my record. 3. I have the right to request an amendment to my record. 4. I have the right to request an accounting of certain disclosures of information in my record. 5. I have the right to request a restriction for use and disclosure of my record. ) /Pg 8 0 R /K [10] >> endobj 95 0 obj << /Type /StructElem /S /H1 /T (All record requests outlined above will be reviewed by the Privacy Officer or their designee. The Privacy Officer or their designee will respond within the confines allowed by law and according to what 51Թ believes is in the best interest of the consumer, others affected by the request and the interests of 51Թ. ) /E (All record requests outlined above will be reviewed by the Privacy Officer or their designee. The Privacy Officer or their designee will respond within the confines allowed by law and according to what 51Թ believes is in the best interest of the consumer, others affected by the request and the interests of 51Թ. ) /Pg 8 0 R /K [21] >> endobj 96 0 obj << /Type /StructElem /S /H1 /T (Responsibilities: ) /E (Responsibilities: ) /Pg 8 0 R /K [20] >> endobj 97 0 obj << /Type /StructElem /S /Figure /P 48 0 R /Pg 8 0 R /K [22] >> endobj 98 0 obj << /Type /StructElem /S /H1 /T (1. As a condition of receiving services at 51Թ, I will be responsible for meeting my ) /E (1. As a condition of receiving services at 51Թ, I will be responsible for meeting my ) /Pg 8 0 R /K [14] >> endobj 99 0 obj << /Type /StructElem /S /H1 /T (financial obligations such as share of cost, co-pays, room and board and any other costs not covered by my insurance. Financial eligibility will be determined monthly. ) /E (financial obligations such as share of cost, co-pays, room and board and any other costs not covered by my insurance. Financial eligibility will be determined monthly. ) /Pg 8 0 R /K [15] >> endobj 100 0 obj << /Type /StructElem /S /H1 /T (a. I will provide 51Թ with accurate financial information so that my share ) /E (a. I will provide 51Թ with accurate financial information so that my share ) /Pg 8 0 R /K [16] >> endobj 101 0 obj << /Type /StructElem /S /H1 /T (of cost may be determined based on my ability to pay. ) /E (of cost may be determined based on my ability to pay. ) /Pg 8 0 R /K [17] >> endobj 102 0 obj << /Type /StructElem /S /H1 /T (b. I will fulfill my financial obligation to 51Թ. c. When necessary, I will make regular payments to 51Թ and discuss with ) /E (b. I will fulfill my financial obligation to 51Թ. c. When necessary, I will make regular payments to 51Թ and discuss with ) /Pg 8 0 R /K [18] >> endobj 103 0 obj << /Type /StructElem /S /P /E (Clients Rights: All programs ) /Pg 8 0 R /K [0] >> endobj 104 0 obj << /Type /StructElem /S /P /E (Revised: 05/2020 ) /Pg 8 0 R /K [1] >> endobj 105 0 obj << /Type /StructElem /S /P /E (Page 2 of 5 ) /Pg 8 0 R /K [4] >> endobj 106 0 obj << /Type /StructElem /S /P /E (Attachment A ) /Pg 9 0 R /K [3] >> endobj 107 0 obj << /Type /StructElem /S /P /E <506F6C69637920232037203130303220436F6E73756D65729073204C6567616C20616E6420436976696C2052696768747320> /Pg 9 0 R /K [4] >> endobj 108 0 obj << /Type /StructElem /S /H1 /T (appropriate staff any changes in my financial situation that would affect my share of cost. ) /E (appropriate staff any changes in my financial situation that would affect my share of cost. ) /Pg 9 0 R /K [6] >> endobj 109 0 obj << /Type /StructElem /S /H1 /T (2. Medi-Cal will be billed for the cost of eligible services and I have provided my Medi-) /E (2. Medi-Cal will be billed for the cost of eligible services and I have provided my Medi-) /Pg 9 0 R /K [7] >> endobj 110 0 obj << /Type /StructElem /S /H1 /T (Cal card today so that a copy can be made and retained in my chart. Once program eligibility has been determined, I will be eligible for the full scope of services for meeting goals toward improvement in functioning and independence. The scope of services shall be described at the time of intake. If the scope of services within the agency is not sufficient to meet my needs, recommendations for additional service and community resources will be made. ) /E (Cal card today so that a copy can be made and retained in my chart. Once program eligibility has been determined, I will be eligible for the full scope of services for meeting goals toward improvement in functioning and independence. The scope of services shall be described at the time of intake. If the scope of services within the agency is not sufficient to meet my needs, recommendations for additional service and community resources will be made. ) /Pg 9 0 R /K [8 9] >> endobj 111 0 obj << /Type /StructElem /S /H1 /T (3. ) /E (3. ) /Pg 9 0 R /K [10] >> endobj 112 0 obj << /Type /StructElem /S /H1 /T (4. I am responsible for actively participating in my treatment, including the development of my ) /E (4. I am responsible for actively participating in my treatment, including the development of my ) /Pg 9 0 R /K [11] >> endobj 113 0 obj << /Type /StructElem /S /H1 /T (treatment goals. I will be expected to meet with program staff to develop a plan for service. This is for both the purpose of addressing my individualized needs, and to meet funding source charting requirements. If I do not participate in developing my treatment plan, I risk not being able to access services until a treatment plan is completed with my input. I also risk my services being closed with 51Թ if I do not collaborate with staff to develop a treatment plan. ) /E (treatment goals. I will be expected to meet with program staff to develop a plan for service. This is for both the purpose of addressing my individualized needs, and to meet funding source charting requirements. If I do not participate in developing my treatment plan, I risk not being able to access services until a treatment plan is completed with my input. I also risk my services being closed with 51Թ if I do not collaborate with staff to develop a treatment plan. ) /Pg 9 0 R /K [12 13] >> endobj 114 0 obj << /Type /StructElem /S /H1 /T (5. I am responsible for attending my appointments with 51Թ staff. If I am unable to ) /E (5. I am responsible for attending my appointments with 51Թ staff. If I am unable to ) /Pg 9 0 R /K [14] >> endobj 115 0 obj << /Type /StructElem /S /H1 /T (keep an appointment, I am responsible for notifying 51Թ in advance. For Outpatient Services, if my case manager \(CSS or PSC\) or Clinician is unable to contact me regularly to provide services on at least a monthly basis, I risk closure of services. If my treatment team is unable to contact me or to meet with me for three consecutive months, my services will be closed and I may go through the Call Center to reconnect with services. ) /E (keep an appointment, I am responsible for notifying 51Թ in advance. For Outpatient Services, if my case manager \(CSS or PSC\) or Clinician is unable to contact me regularly to provide services on at least a monthly basis, I risk closure of services. If my treatment team is unable to contact me or to meet with me for three consecutive months, my services will be closed and I may go through the Call Center to reconnect with services. ) /Pg 9 0 R /K [15 16] >> endobj 116 0 obj << /Type /StructElem /S /H1 /T (6. I am responsible for being respectful of others whenever I am within a 51Թ program ) /E (6. I am responsible for being respectful of others whenever I am within a 51Թ program ) /Pg 9 0 R /K [17] >> endobj 117 0 obj << /Type /StructElem /S /H1 /T (site or with a 51Թ staff in the field. I am responsible for refraining from behavior that is verbally or physically aggressive, offensive and/or harmful to other persons. Such behavior can result in services being interrupted or terminated. For example, abusive language \(including racial, ethnic or sexual slurs\), or threatening violence while on 51Թ site property is not acceptable behavior. ) /E (site or with a 51Թ staff in the field. I am responsible for refraining from behavior that is verbally or physically aggressive, offensive and/or harmful to other persons. Such behavior can result in services being interrupted or terminated. For example, abusive language \(including racial, ethnic or sexual slurs\), or threatening violence while on 51Թ site property is not acceptable behavior. ) /Pg 9 0 R /K [18 19] >> endobj 118 0 obj << /Type /StructElem /S /H1 /T (7. I understand that if I arrive at the program under the influence of alcohol and / or drugs I ) /E (7. I understand that if I arrive at the program under the influence of alcohol and / or drugs I ) /Pg 9 0 R /K [20] >> endobj 119 0 obj << /Type /StructElem /S /H1 /T (will be asked to leave. ) /E (will be asked to leave. ) /Pg 9 0 R /K [21] >> endobj 120 0 obj << /Type /StructElem /S /H1 /T (a. If I drove to the program I will surrender my keys to staff and other arrangements will be ) /E (a. If I drove to the program I will surrender my keys to staff and other arrangements will be ) /Pg 9 0 R /K [22] >> endobj 121 0 obj << /Type /StructElem /S /H1 /T (made for my transportation home. ) /E (made for my transportation home. ) /Pg 9 0 R /K [23] >> endobj 122 0 obj << /Type /StructElem /S /H1 /T <622E204966204920646F6E907420616C6C6F77207468652070726F6772616D20746F2068656C70206D652067657420686F6D6520736166656C792C207468652070726F6772616D206973206F626C69676174656420746F20> /E <622E204966204920646F6E907420616C6C6F77207468652070726F6772616D20746F2068656C70206D652067657420686F6D6520736166656C792C207468652070726F6772616D206973206F626C69676174656420746F20> /Pg 9 0 R /K [24] >> endobj 123 0 obj << /Type /StructElem /S /H1 /T (report me to the authorities for driving under the influence of drugs and/or alcohol. ) /E (report me to the authorities for driving under the influence of drugs and/or alcohol. ) /Pg 9 0 R /K [25] >> endobj 124 0 obj << /Type /StructElem /S /H1 /T (Additional Resources:) /E (Additional Resources:) /Pg 9 0 R /K [26] >> endobj 125 0 obj << /Type /StructElem /S /H1 /T (Following is a list of resources available to clients who would like additional assistance. Any Client of 51Թ may contact: ) /E (Following is a list of resources available to clients who would like additional assistance. Any Client of 51Թ may contact: ) /Pg 9 0 R /K [0] >> endobj 126 0 obj << /Type /StructElem /S /Figure /P 49 0 R /Pg 9 0 R /K [28] >> endobj 127 0 obj << /Type /StructElem /S /Figure /P 49 0 R /Pg 9 0 R /K [29] >> endobj 128 0 obj << /Type /StructElem /S /P /E (Clients Rights: All programs ) /Pg 9 0 R /K [1] >> endobj 129 0 obj << /Type /StructElem /S /P /E (Revised: 05/2020 ) /Pg 9 0 R /K [2] >> endobj 130 0 obj << /Type /StructElem /S /P /E (Page 3 of 5 ) /Pg 9 0 R /K [5] >> endobj 131 0 obj << /Type /StructElem /S /Figure /P 49 0 R /Pg 9 0 R /K [27] >> endobj 132 0 obj << /Type /StructElem /S /P /E (Attachment A ) /Pg 10 0 R /K [6] >> endobj 133 0 obj << /Type /StructElem /S /P /E <506F6C69637920232037203130303220436F6E73756D65729073204C6567616C20616E6420436976696C2052696768747320> /Pg 10 0 R /K [7] >> endobj 134 0 obj << /Type /StructElem /S /H2 /T (51Թ Quality Improvement Department For questions re: complaints, grievances, privacy, access to medical records 1940 The Alameda, San Jose, CA 95126 \(408\) 642-6073 Individuals who are/were clients of Employment Services may contact: ) /E (51Թ Quality Improvement Department For questions re: complaints, grievances, privacy, access to medical records 1940 The Alameda, San Jose, CA 95126 \(408\) 642-6073 Individuals who are/were clients of Employment Services may contact: ) /Pg 10 0 R /K [8] >> endobj 135 0 obj << /Type /StructElem /S /Figure /P 50 0 R /Pg 10 0 R /K [14] >> endobj 136 0 obj << /Type /StructElem /S /H2 /T (The Department of Rehabilitation Mediation and Fair Hearing office that has information online for how to navigate that process: https://www.dor.ca.gov/Home/FairHearings. The Client Assistance Program \(CAP\) may also be available to assist you during the entire rehabilitation and or appeals process. The CAP Program is administered by Disability Rights California \(DRC\). Consumers can reach their CAP advocate by calling DRC's statewide toll-free number at 1-800-776-5746 or TTY: 1-800-719-5798. CAP advocates are not employees of the Department. They serve as independent advocates. If you cannot achieve resolution to your concerns at the local level, CAP may help you request, prepare for and/or represent you at a mediation meeting, Administrative Review or a Fair Hearing. ) /E (The Department of Rehabilitation Mediation and Fair Hearing office that has information online for how to navigate that process: https://www.dor.ca.gov/Home/FairHearings. The Client Assistance Program \(CAP\) may also be available to assist you during the entire rehabilitation and or appeals process. The CAP Program is administered by Disability Rights California \(DRC\). Consumers can reach their CAP advocate by calling DRC's statewide toll-free number at 1-800-776-5746 or TTY: 1-800-719-5798. CAP advocates are not employees of the Department. They serve as independent advocates. If you cannot achieve resolution to your concerns at the local level, CAP may help you request, prepare for and/or represent you at a mediation meeting, Administrative Review or a Fair Hearing. ) /Pg 10 0 R /K [2] >> endobj 137 0 obj << /Type /StructElem /S /Figure /P 50 0 R /Pg 10 0 R /K [16] >> endobj 138 0 obj << /Type /StructElem /S /Figure /P 50 0 R /Pg 10 0 R /K [17] >> endobj 139 0 obj << /Type /StructElem /S /H2 /T (Individuals who are/were clients through the Santa Clara County Behavioral Health Services Department may contact: ) /E (Individuals who are/were clients through the Santa Clara County Behavioral Health Services Department may contact: ) /Pg 10 0 R /K [0] >> endobj 140 0 obj << /Type /StructElem /S /Figure /P 50 0 R /Pg 10 0 R /K [20] >> endobj 141 0 obj << /Type /StructElem /S /Figure /P 50 0 R /Pg 10 0 R /K [21] >> endobj 142 0 obj << /Type /StructElem /S /H2 /T (Santa Clara Valley Health & Hospital System Behavioral Health Services Department www.sccbhd.org 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#350, MS: 29-07 San Jose, CA 95131 \(408\) 324- 2148 \(408\) 324- 2160 ) /Pg 10 0 R /K [12 13] >> endobj 147 0 obj << /Type /StructElem /S /H2 /T (Any Client of 51Թ may contact the following organization for assistance: ) /E (Any Client of 51Թ may contact the following organization for assistance: ) /Pg 10 0 R /K [1] >> endobj 148 0 obj << /Type /StructElem /S /Figure /P 50 0 R /Pg 10 0 R /K [24] >> endobj 149 0 obj << /Type /StructElem /S /P /E (Clients Rights: All programs ) /Pg 10 0 R /K [4] >> endobj 150 0 obj << /Type /StructElem /S /P /E (Revised: 05/2020 ) /Pg 10 0 R /K [5] >> endobj 151 0 obj << /Type /StructElem /S /P /E (Page 4 of 5 ) /Pg 10 0 R /K [9] >> endobj 152 0 obj << /Type /StructElem /S /Figure /P 50 0 R /Pg 10 0 R /K [15] >> endobj 153 0 obj << /Type /StructElem /S /Figure /P 50 0 R /Pg 10 0 R /K [18] >> endobj 154 0 obj << /Type /StructElem /S /Figure /P 50 0 R /Pg 10 0 R /K [19] >> endobj 155 0 obj << /Type /StructElem /S /Figure /P 50 0 R /Pg 10 0 R /K [22] >> 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