Parenting Classes Intake

I hereby give my consent to Avance, Inc. to receive my collect my personal information via this intake form. This form will be emailed to Avance and stored in a protected file. Avance complies with HIPPA guidelines and regulations.

In addition, Informed Consent means that I am:

• Informed of my legal rights as a client.

• Informed of my responsibilities, including conformity to program rules and regulations.

• Informed of how I am protected under the rules of confidentiality from disclosure of information I have not authorized.

CLIENT RIGHTS STATEMENT
In seeking services from AVANCE, Inc., I have the following rights:

1. Access to services will not be denied on the basis of race, religion, ethnicity, disability, sexual orientation, or HIV status.

2. Services will be provided in the least restrictive environment available.

3. Confidentiality of HIV/AIDS status as specified in Section 2060.321 of the administrative rule.

4. The right to nondiscriminatory access to services as specified in the American’s with Disabilities Act of 1990 (42 USC 121001).

5. The right to give or withhold informed consent regarding treatment and regarding confidential information about myself.

6. A description of the route of appeal available if I disagree with the organization’s decision or policies.

7. Any complaints must be addressed directly to your assigned counselor. If the issue is unresolved, you must contact the director of Avance, Jorge Argueta. If the issue continues to be unresolved, contact Ivan Zdero at (847) 346-7900.

8. Confidentiality of Client records as specified in Section 2060.319 of the Part.

9. The right to refuse treatment or any specific treatment procedure and a right to be informed of the consequences resulting from such refusal.

I certify that I have read my legal rights as a client at Avance.

NO REIMBURSEMENT POLICY
REINSTATEMENT FEE DUE TO TERMINATION

I understand that Avance, Inc. will not reimburse any fees paid by me. These fees are NOT reimbursed even if I decide not to return to complete the program.

I also understand that if I am TERMINATED from the program, I need to pay a my balance and a administrative/reinstatement fee in order to resume my classes at Avance, Inc. and to cover the costs of the continuing care review and/or additional intake/screening documentation.