Primo Center is committed to ensuring that you receive professional and humanistic services directed toward your needs in a manner that protects your dignity, feelings of self-worth, and self-determination. To this end, the following Statement of Rights has been formulated and will be distributed to clients at intake and annually:

CIVIL RIGHTS

• Right to be treated with dignity and respect and to be free from abuse, neglect, exploitation, and sexual harassment.
• Retain all rights, benefits, and privileges guaranteed by law.
• Rights are protected in accordance with Chapter 2 of the Mental Health and Developmental Disabilities Confidentiality Act [405 ILCS 5].
• Services will be explained using language or a method of communication the client understands, and documentation of such explanation will be placed in the client’s record.
• Right to have disabilities accommodated as required by the Americans With Disabilities Act, Section 504 of the Rehabilitation Act, and the Human Rights Act [775 ILCS 5]. The agency will make reasonable accommodations for clients with disabilities.

CONFIDENTIALITY

• Right to confidentiality as governed by the Confidentiality Act [740 ILCS 110] and the Health Insurance Portability and Accountability Act of 1996 (45 CFR 160 & 164).
• All information concerning you is held confidential and released only through procedures consistent with the law and professional ethics. Your records can be subpoenaed by the courts without your permission; however, should this occur, the situation will be discussed with the agency’s legal counsel and released only with a court order.
• Right to review and approve any information being requested by another provider giving services to you. You must sign a release for your information to be forwarded (written or communicated).

DISCRIMINATION

Primo Center does not discriminate against patients or clients based upon the individual’s inability to pay; whether payment for services would be made under Medicare, Medicaid, or CHIP; or the individual’s race, color, sex, national origin, disability, religion, age, sexual orientation, or gender identity. Services will be provided in a trauma-informed manner, with the understanding that time is of the essence.

TREATMENT

• Right to an Individual Service Plan for services and the expectation to participate in its development. Your plan will be developed with your input no later than 30 days after completing an assessment and reviewed at least once every six months.
• Right to know the name and professional credentials of anyone working with you.
• You may request to participate in any staff meeting regarding yourself.
• You may review your clinical records upon written request.
• You will be assigned a therapist or counselor who will assist you in obtaining services as agreed upon in your individual plan for services.
• Right of Informed Consent with regard to all aspects of services provided by Primo Center.
• You will be advised of positive effects and possible complications of any drugs or medications prescribed by a physician involved in your services.
• Right to refuse to participate in, or be interviewed for, research purposes.
• Right to refuse treatment or services without incurring any negative consequences from the agency at any time.
• Right to confer with family, attorney, physician, and others at any time.
• Right to mental health services in the least restrictive setting.

EVALUATION

Consistent with providing professional and quality services, you will be given the opportunity to evaluate all aspects of your services and the personnel with whom you were involved through satisfaction surveys and other organizational improvement activities. You will be asked to evaluate your service, in writing, during or upon completion of the same.

GRIEVANCE PROCEDURE

• If you feel your services have not been provided fairly or reasonably, you may present your concerns in person, in writing, or anonymously by completing the Grievance Form and submitting it to your therapist or counselor’s immediate supervisor. You may also speak with your therapist or counselor’s supervisor or email Felicia Blakley, CEO of Primo Center, at felicia.blakley@primocenter.org. You have the right to appeal adverse decisions up to and including the Chief Executive Officer. The CEO’s decision will be the final administrative decision. Primo Center welcomes your input and feedback, and there will be no negative consequences for filing a complaint.
• You have the right to legal resources.
• You have the right to contact the public payer/HFS and be informed of their process for reviewing grievances.
• You have the right to contact the following agencies if you feel your rights are being violated:

• Services cannot be denied, suspended, terminated, or reduced for exercising any of your rights.

MUTUAL RESPONSIBILITIES OF AGENCY AND CLIENT

• Deciding on the plan for services.
• Determining the frequency and duration of services.
• Involving family members or significant others in care decisions.

ADMISSIONS

You have the right to receive the appropriate service(s) based on your identified needs and a sound clinical assessment.

HIPAA

By signing below, I hereby acknowledge receipt of Primo Center’s Privacy Notice and consent to the uses and disclosures described in the Privacy Notice.

Each client shall be given a copy of the Statement of Rights for his/her personal use.

I have read and understood the Statement of Rights. A copy was given to and reviewed with the client and parent/foster parent/guardian on this date: _____________________________

Participant’s Signature: ___________________________
Staff’s Signature: ___________________________