CLIENT/GUARDIAN RELEASE
Use this form for all clients (Supported Living and Non-Supported Living) on Intake and Annually thereafter. This agreement between the provider and the client and/or client's guardian is to assist the provider with collecting information about the client in order to provide the client with requested and authorized services and to fulfill the requirements of all agencies who direct, authorize, monitor, and audit the provider. The provider requests that the client and/or client's guardian agree to provide essential information so that the provider can provide quality, comprehensive services. The information requested at various times during the year (Intake, Quarterly, Annually) is protected under HIPAA and it is the policy of the provider to protect all client information against loss, defacement, tampering, and use by unauthorized persons. Information is used on an "as needed" basis to provide requested, authorized services to the client. The client and/or the client's guardian may at anytime request a copy of any paperwork or form used by the provider to collect information. Information requested may include, but is not limited to:

- Medications and Medication Regime	- Physical Health	- Mental Health	- Dental Health

- Health Appointments	- Diet	- Financial Information	- Skills, Abilities, Knowledge

- Behavioral Issues	- Strengths	- Weaknesses	- Interests, Goals, Dreams

Ensure the client and/or client's guardian has copies of the client's SP, IP, and Service/Job Descriptions.
Individual	Date
Staff Name
Services (list)
Yes	No	Does the client have a guardian?	Name of Guardian
Yes	No	Does the guardian/client have a copy of the client's Support Plan and Implementation Plan?
Yes	No	Does the guardian/client understand the goals on the client's Support Plan?
Yes	No	Does the guardian/client understand the services provided to the client?
Yes	No	Does the guardian/client have a copy of the job description(s) for the service(s) provided to the client?
Yes	No	Does the provider have a copy of the client's guardianship papers?
Yes	No	Does the client have expectations of the provider not covered in the provider's job description or the Support Plan? (Describe)

Yes	No	Does the guardian have expectations of the provider not covered in the provider's job description or the Support Plan? (Describe)

By signing this release agreement, I

Print Client or Guardian Name

agree that I understand the services provided and the need to provide information to the provider and I also

agree to allow the provider to collect information in order to provide the services requested and authorized.

This agreement, signed (month/day/year) is valid for one year.

Next Validation Date (month/day/year):

Individual	Signature	Date
Client
Guardian
Staff