My signature below is acknowledgement that the following information was reviewed all explained to me during the intake process:

• Privacy (HIPAA.) Laws
• Client Rights as Participants
• Grievance Procedure
• Confidentiality of Records and Release of Information
•    Description of Services offered

As a client or designee of the client, my signature below indicates that I understand the information above and that I agree to adhere to the policy, protocol and/or procedures to each of the items as listed as they relate to me at any given time as a participant in Family Intervention Partners programs.