CHW Packet – Initialing & SigningCHW Packet - Initialing and SigningFamily Connections, LLC 1643 Warwick Avenue, #200, Warwick RI 02889 Phone: 401-952-8188 Fax: 401-385-9410 familyconnections@familyconnectionsri.com familyconnectionsri.com Please enable JavaScript in your browser to complete this form.LayoutClient Name *FirstLastClient ID:By Initialing and signing below, I attest that I have been provided with the documents outlined below by a Community Connections staff member, and that they have explained these documents to me in a manner and language that I understand. I also understand that I have the right to ask questions, end services and report of services that I feel are not appropriate for me without fear of retaliation or losing services. I also understand that I have a right to receive copies of any documents that I sign in the course of received services from Community Connections.Client Initial:Community Connections Community Health Workers limits of confidentiality. Client InitialClient Rights and ResponsibilitiesClient InitialCommunity Connections Grievance PolicyClient InitlalNotice of Privacy PracticesClient InitlalAl inicializar y firmar a continuación, doy fe de que un miembro del personal de Community Connections me ha proporcionado los documentos que se describen a continuación, y que me han explicado estos documentos de una manera y lenguaje que entiendo. También entiendo que tengo derecho a hacer preguntas, terminar los servicios e informar de los servicios que siento que no son apropiados para mí sin miedo a represalias o de perder servicios. También entiendo que tengo derecho a recibir copias de cualquier documento que firme en el curso de los servicios recibidos de Community Connections.Inicial del Cliente:Limites De confidencialidad de Community Connections Community Health WorkersInicial del Cliente:Derechos y responsabilidades del clienteInicial del Cliente:Política de quejas de Community ConnectionsInicial del Cliente:Aviso de prálcticas de privacidadInicial del Cliente:LayoutClient Signature/firma del cliente Clear Signature Date / FechaLayout (copy)Parent-Guardian signature/ Firma del padre-tutor Clear Signature Date / FechaLayout (copy) (copy)Community Connections staff /Personal de Community Connections Clear Signature Date / FechaLayout (copy)Print FC Staff Name *FC EmailFC Staff Signature Clear Signature Date / FechaSubmit