SOUTHERN ILLINOIS REGIONAL SOCIAL SERVICES, INC. CLIENT’S RIGHTS This statement summarizes your rights as a client at SIRSS. Services will be provided to you and/or your family members without discrimination on the basis of race, ethnic origin, age, gender, spiritual beliefs, sexual orientation, disability, HIV status, socioeconomic status, or status as a veteran, and as specified in the Americans With Disabilities Act of 1990 (42 USC 12101). You retain all rights, benefits, and privileges guaranteed by law. You will be treated with respect and consideration, in a manner that is responsive to your needs, abilities, and preferred means of communication. You have the right to: Participate in the development of an Individualized Treatment Plan and/or Service Plan. Know the name and professional credentials of anyone working with you and express your preferences regarding service providers. Be treated in the least restrictive environment appropriate for your condition. Review your current clinical records under the supervision of your counselor (written request prior to review required). Give or withhold informed consent regarding treatment and regarding confidential information. Refuse services or any specific service, and the right to be informed of the consequences resulting from a refusal of such services. Refuse to participate in research conducted at SIRSS. Refuse specific medication to the extent permitted by law. Terminate services at any time. (The courtesy of advance notification of intent to terminate is requested.)
All information will be held confidential and released only through procedures consistent with the Illinois Mental Health and Developmental Disabilities Code Chapter II, the Illinois Mental Health and Developmental Disabilities Confidentiality Act, the Code of Federal Regulations (42 CFR Part 2 and 45 CFR Parts 160 and 164 - HIPAA), and agency policies. SIRSS will not release any information without having a signed and witnessed form authorizing the disclosure of your records, except as permitted by law and required by governmental regulations. You have the right to review any information being released. Under certain circumstances, human service providers are mandated to disclose specific information and are authorized by law to do so without obtaining a client’s consent for disclosure. These circumstances include: When staff determine that a client is a danger to him or herself or others. Suspected child abuse and/or child neglect, which must be reported to the Illinois Department of Children and Family Services. Suspected abuse or neglect of a person 60 years or older, which must be reported to the Illinois Department of Aging. Suspected abuse or neglect of a client, which must be reported to the Illinois Department of Human Services’ Office of the Inspector General. When a client’s records are subpoenaed by a court of law.
SIRSS staff adhere to a strict Code of Professional Practice and are committed to maintaining the highest ethical standards. The welfare of each client is our highest priority. At no time will clients be subjected to any form of abuse including, but not limited to, physical abuse or punishment, psychological abuse, retaliation, humiliation, neglect, and financial or other exploitation. If you have concerns about your treatment, you have the right to present grievances and to appeal adverse decisions of the Agency up to and including the Executive Director. The Executive Director’s decision on a grievance shall constitute a final administrative decision. You have the right to total confidentiality regarding your HIV/AIDS status and are not required to be tested for HIV antibodies as part of the admission criteria. If you desire HIV testing, SIRSS will refer you to confidential testing sites. You will not be denied, suspended, or terminated from services or have services refused for exercising any of your rights. You have the right to contact the following agencies: Guardianship & Advocacy Commission 618-833-4897
7 Cottage Drive 312-793-5937 - TTY
Anna, IL 62906 Equip for Equality 800-758-0464 - voice or TTY
427 East Monroe Street
Springfield, IL 62705 Dept. of Children & Family Services 217-785-2509
406 East Monroe Street 217-524-3715 - TTY
Springfield, IL 62701 Dept. of Human Services 800-843-6154 Division of Mental Health 800-447-6404 - TTY 100 North 9th Street
Springfield, IL 62765-1300
Division of Alcoholism & Substance Abuse 866-213-0548 100 West Randolph Street; Suite 5600 312-419-8432 - TTY Chicago, IL 60601 Office of the Inspector General 800-368-1463 - voice or TTY 901 Southwind Road Springfield, IL 62703 You have the right to contact the public payer at: Dept. of Human Services 800-252-8635 401 S. Clinton St., 3rd Floor 800-447-6404 - TTY Chicago, IL 60607 I have read, or have had read to me, and have asked and had answered to my satisfaction any questions I had regarding the Client’s Rights statement. I have received a copy of these rights. Additionally, I acknowledge receiving the SIRSS Notice of Privacy Practices, and have had the opportunity to ask any questions I may have had regarding the notice. _______________________________________
Client Signature Date Parent/Guardian Signature Date (Required for clients under 18 years of age) ______________________________________________________________________________________ I have explained the above rights to the client and I believe she/he understands these rights to the best of their ability. ________________________________________
Clinician Signature Date | 
