Client Rights / Grievances Document Client Rights: I understand my basic rights as a client. These rights include: (List the specifics of your agency’s client rights policy) Grievance Policy: I understand that if I have a complaint/grievance, I should: (List the specifics of your agency’s grievance policy) _____ I understand that I have a right to contact the agencies below at any time to discuss my complaint/grievance: DWI Services, Justice Systems Innovations NC Mental Health/Developmental Disabilities/Substance Abuse Services Shenita Billups Donna Brown 3008 Mail Service Center Raleigh, NC 27699-3008 Phone: 919-733-0566 Fax: 919-508-0963 Carolina Substance Abuse Professional Practice Board Katie Gilmore, Associate Executive Director P.O. Box 10126 Raleigh, NC 27605 Disability Rights NC 3724 National Drive, Suite 100 Raleigh, NC 27612 (877) 235-4210 or (919) 856-2195 I certify that I have received a copy of this Client Rights/Grievance Policy Client’s Signature: _______________________________________________ Date:__________ Counselor’s Signature/Credential: __________________________________ Date: __________
Client Rights / Grievances Document Client Rights: I understand my basic rights as a client. These rights include: (List the specifics of your agency’s client rights policy) Grievance Policy: I understand that if I have a complaint/grievance, I should: (List the specifics of your agency’s grievance policy) _____ I understand that I have a right to contact the agencies below at any time to discuss my complaint/grievance: DWI Services, Justice Systems Innovations NC Mental Health/Developmental Disabilities/Substance Abuse Services Shenita Billups Donna Brown 3008 Mail Service Center Raleigh, NC 27699-3008 Phone: 919-733-0566 Fax: 919-508-0963 Carolina Substance Abuse Professional Practice Board Katie Gilmore, Associate Executive Director P.O. Box 10126 Raleigh, NC 27605 Disability Rights NC 3724 National Drive, Suite 100 Raleigh, NC 27612 (877) 235-4210 or (919) 856-2195 I certify that I have received a copy of this Client Rights/Grievance Policy Client’s Signature: _______________________________________________ Date:__________ Counselor’s Signature/Credential: __________________________________ Date: __________