Facility Name: Client’s Name: To be signed by the Client or their representative. I, _________________________________________________________________________ of ________________________________________________________________________ ________________________________________________________________________ having been consulted by staff member's name and title about a proposal for me / my ___________________________ to be relocated from room number _________ to room _________ and having the reasons (as set out below) fully explained to me, hereby agree to such relocation as soon as it can be arranged. The reason for the relocation of my / my ________________________________’s place of residence given is: DATED this day of 20 SIGNED: WITNESS: Indicate: Client / Person Responsible Name: Client Liaison Use Scanned: PeoplePoint Copy placed on Client’s TRIM file
Facility Name: Client’s Name: To be signed by the Client or their representative. I, _________________________________________________________________________ of ________________________________________________________________________ ________________________________________________________________________ having been consulted by staff member's name and title about a proposal for me / my ___________________________ to be relocated from room number _________ to room _________ and having the reasons (as set out below) fully explained to me, hereby agree to such relocation as soon as it can be arranged. The reason for the relocation of my / my ________________________________’s place of residence given is: DATED this day of 20 SIGNED: WITNESS: Indicate: Client / Person Responsible Name: Client Liaison Use Scanned: PeoplePoint Copy placed on Client’s TRIM file
Clients-Consent-to-Relocate.docx