I authorize DV Therapy Inc to charge the amount listed above to the credit card provided herein. I agree to pay for this purchase in accordance with the issuing bank cardholder
agreement.
CLIENT/FAMILY RIGHTS AND RESPONSIBILITIES
You have the RIGHT to:
-
Effective behavioral treatment
-
Be treated with dignity and respect
-
Receive service that is considerate and respectful of your spiritual needs, beliefs and values
-
Receive services in a safe setting, free of all forms of abuse or harassment
-
Receive services without discrimination of age, ability, gender, race, spiritual beliefs, ethnic origin, marital status, sexual orientation, or financial status
-
Receive as much information needed about treatments in order to provide informed consent or refuse treatment
-
Access information on the progress of treatments
-
Know the benefits and potential limitations of proposed treatments
-
Refuse to participate in clinical research
-
Access your records within a reasonable timeframe, except specified by law
-
Express concerns or complaints about services without fear that the quality of your services will be affected
-
File a grievance with DV Therapy Inc. by calling (323) 426-6402 or by writing:
Client Relations
Attn: Iddo DeVries M.S. CCC-SLP
1080 S La Cienega Blvd Suite 208
Los Angeles CA 90035
-
File a grievance with the Secretary of the Department of Health and Human Services:
200 Independence Avenue, SW
Room 509F
HHH Building
Washington, DC 20201
orcmail@hhs.gov
You have the RESPONSIBILITY to:
-
Refrain from demands for inappropriate or treatments that are not evidence-based
-
Keep appointments and minimize cancellations
-
Respect the rights, property, and privacy of other DV Therapy, Inc. clients and staff
-
Report accurate and complete information regarding all matters relevant to treatment
-
Be informed and ask questions regarding your treatment
-
Follow the directions of the clinicians regarding treatment
-
Promptly pay your bills
-
Be an active participant in therapeutic treatment
-
Conduct yourself in a respectful manner
Remember: Being a good consumer does not mean being a silent partner!
ASK questions when you have them
SPEAK UP when you have concerns
EXPRESS YOUR APPRECIATION when you are satisfied with your treatment