Agree Disagree. Use of first name only: ........ Agree Disagree Use of full name: .................
Agree Disagree. Use of full name: ..............
Agree Disagree. INDIVIDUAL RIGHTS AND RESPONSIBILITIES I have received a written copy of the RHC Client / Resident Rights and Responsibilities (attached). I understand if I have any questions or concerns I can contact an RHC Supervisor, the Habilitation Plan Administrator, the Case Manager Resource Nurse, or the Resident Care Coordinator. INITIAL PHYSICIAN ORDERS FOR LIFE-SUSTAINING TREATMENT (POLST) Does the resident have a POLST / advance directive? If interested in obtaining a POLST or to get more information on advance directives, contact the resident’s medical provider. Yes INITIAL No ADVOCACY INFORMAT ION If you have concerns about abuse or neglect reporting, or have concerns related to resident’s rights, there are advocacy agencies not affiliated with the RHC you can contact for assistance. These include: Disability Rights Washington, DD Ombudsman, Nursing Home Ombudsman program, or Complaint Resolution Unit (CRU) Hotline. CRU Number: 0-000-000-0000 To file a grievance, see the attached Grievance Policy. INITIAL SIGNATURE DATE RELATIONSHIP Parent Guardian Relative (relationship): Superintendent / Custodial Guardian RESIDENT ’S NAME DDA NUMBER RESIDENCE BIRT HDATE Disclaimer: Services at this RHC are based on the resident’s assessed needs and if you request services outside the interdisciplinary team determination, you are responsible for payment, transportation, and setup for that service. If you feel the resident needs a service not provided by the facility, contact the Habilitation Plan Administrator, Case Manager Resource Nurse, or Resident Care Coordinator so they can facilitate a team meeting to discuss the recommendation. ATTACHMENT: RHC Client / Resident Rights and Responsibilities RESIDENTIAL HABILITATION CENTER (RHC) Consent and Service Agreement RHC Client / Resident Rights and Responsibilities
Agree Disagree. I acknowledge that any breach of this agreement may result in the removal of my information for the NDSLIC distribution lists. Agree Disagree
Agree Disagree. RESIDENT’S NAME DDA NUMBER RESIDENCE BIRTHDATE
Agree Disagree. Use of name:....................... Agree Disagree Friend exchanges: ..............
Agree Disagree. Use of artwork:....................
Agree Disagree. For your added security, the front and back doors have a 4-digit code exclusive to your group’s stay. Only management and guests will have access during your time with us. The code will be provided to you at the time of check-in. Policies & Procedures The Craft House Retreat in Jacksboro, Texas welcomes you as our guest. To make everyone’s stay as enjoyable as possible, we ask that every guest familiarize yourself with the following policies and procedures, and agree to abiding by these regulations. For groups, we request one group coordinator who shall be responsible for deposits, payments, additional coordination, and sharing of our policies and procedures with the group to ensure a pleasant stay and return of your deposits. Rates Reservations are based on a two-night, two room minimum stay. Each room is $255/night (sleeps 3) and includes use of the home, kitchen, breakfast, and drink service. Workshops are additional fees added to the base rates. Day rates for quilters and crafters are $50 per day and include drink service. Please call us to coordinate your reservation for special events. Reservations & Cancellations Reservations are based on a two-night, two-room minimum stay. Each room is $255/night (sleeps 3) with additional guests at $85/night. Open-stays* are $85/person per night. Rates include use of the maker-space, kitchen, a daily breakfast, and drink service. Workshops are in addition to the above base rates. Day rates are available during open-stays* for $40/person including drink service. For special events, please call to coordinate. *Open-stays are when a group minimum has not been met, or when a group is open to having individuals join them during their stay. Each reservation requires a two-night minimum stay, and groups must have a minimum of six people – or a two bedroom reservation. If a group is willing to share the house with other guests, we are glad to open up other rooms to meet your minimum requirement (an “open-stay”). A deposit of $135/room, or $45/person, is required at the time of booking your reservation. The balance will be due 45 days prior to your arrival. If balances are not received, deposits may be forfeited and reservations cancelled. All cancellations require a $25.00 processing fee. For those made prior to 60 days or more of the stay will be fully refunded or transferred to a future stay within 12 months. For cancellations made 31 - 59 days prior, 50% will be refunded; and no refund for cancellations made 30 days pr...
Agree Disagree. The Newcomer Family was open to sharing information immediately. The Newcomer Family does not appear to be reluctant to request my assistance. The Newcomer Family is learning to become more self- sufficient. The Newcomer family and I (the CN) handle our language challenges adequately.
Agree Disagree. The Newcomer Family never fully opened up to me. The Newcomer Family gradually became less reluctant to request my assistance. The Newcomer Family became more self- sufficient during our 3-month match period.
