I have received the PWTH Client Handbook, and reviewed it with the intake counselor. By initialing
below, I am acknowledging that I have reviewed each area below, and asked questions as needed to
fully understand each section and subject below. (Initial next to each section to acknowledge)

Consumer Rights Notification:
I am initialing that I have been offered and/or given a copy of the following:
We have received the synopsis of the Consumer Bill of Rights in the Consumer Handbook which contains
my full Rights & Grievance Policy

• I have read and understand my rights as a consumer
• I have been offered a full copy of my rights and this grievance policy
• I also understand that I may file a Grievance as described in the policy, to have a local advocate
  assist me, to receive a call, verbal, or written response to my complaint within a timely manner,
  and to appeal the resolution if I am not satisfied with the outcome. If, for any reason, I feel that I
  am being denied these rights or penalized for exercising this right, I may make an additional
  appeal to the Department of Mental Health and Substance Abuse Services at the address and
  number listed on the grievance form or as posted in all lobby/reception areas

Case management: I have been offered case management services: I/We

Consent For Follow Up:
I, (Patient, Parent, or Legal Guardian if applicable) authorize Pathway to Hope LLC, to contact me by phone / mail / in person for the purpose of evaluation of treatment progress, client satisfaction and other information as deemed necessary by the staff in order to enhance the quality of care. The following contact information may be helpful to locate me in the event that my address and phone have changed: