Form Dss 6237 – Fill Out and Use This PDF

CLIENT RIGHTS FORM (DSS-6237)

Refugee Service Provider Name:

As clients of this Refugee Service Provider you are entitled to certain rights which include the right:

to participate in the development of a service plan and to be informed of each party’s expectations.

to the least restrictive/intrusive service plan that is appropriate.

to expect that no request for information about you will be released to others without your written consent.

to access your client file upon request for the purpose of review.

to have your identity protected in any published reports, statistics, case summaries, films or other media without your written permission.

to not be discriminated against because of race, religion, color, age, national origin, disability, gender, sexual orientation, or marital status.

to not participate in public appearances, required to make public statements of gratitude to the agency or participate in research activities.

to not be subjected to sexual harassment, and/or any physical, emotional or verbal abuse.

to refuse any service offered by the refugee service provider. However, refusal of these services may result in termination of benefits and other consequences explained by the staff. Services may be terminated; (1) if you move away from the provider service area or (2) you refuse to cooperate with the refugee service provider.

to express dissatisfaction with services provided and file a grievance. If you have problems contact:

1st – Case Manager

Phone Number

2nd – Case Manager Supervisor

3rd – Area Manager:

4th – Agency Refugee Director

5th – NC State Refugee Coordinator:

Any questions regarding these rights should be discussed with your caseworker.

Agency Staff Signature

Date

Please sign this form after you have finished reading it or it has been explained to you.

Client’s Signature

Date

I certify that the client understands the rights outlined above.

Witness / Translator

Date

The original Client’s Rights form is to be maintained in the client’s record with a copy going to the client.

DSS-6237 (Revised 4/1/05) Economic Services-Refugee

	Instructions for Completing the
	NC Refugee Client Rights Form (DSS-)
Refugee Service
Provider:	Enter the name of the organization that is providing services to the client.
Caseworker:	Enter the name of the caseworker that the client has been assigned and their phone number.
Case Manager
Supervisor:	Enter the name of the case manager supervisor that is directly supervising the caseworker assigned
	to the client. If this is not applicable, write N/A in the space provided.
Area Manager:	Enter the name of the area manager who is directly in charge of the office where the client is
	receiving services. If this is not applicable, write N/A in the space provided.
Agency Refugee
Director:	Enter the name of the agency refugee director from whom the client is receiving services.
NC State Refugee
Coordinator:	Enter the name of the state of North Carolina’s refugee coordinator in the space provided.
Agency Staff
Signature:	The agency staff member who is completing this form must sign and date the form in the spaces
	provided.
Client’s Signature:	The client must sign and date in the spaces provided.
Witness/Interpreter:	The witness or interpreter must sign and date certifying that the client understands the rights
	outlined in this form.

The original Client’s Rights form is to be maintained in the client’s record with a copy going to the client.

DSS-6237 (Revised 4/1/05) Economic Services-Refugee