Informed Consent for General Rights Modification

Before you begin (for providers and case managers)

Think about what is being proposed and why, instead of starting by simply filling out this form. Is a Rights Modification really necessary, and if so, must it look exactly as you initially envisioned it? Be creative in thinking about alternative approaches! What else might work with this individual? What has worked with others in similar situations in the past? Have you discussed with the individual what their preferences and needs are? Have you afforded them the opportunity to work with people of their choosing (including advocates, peers, people who help them with supported decision-making, friends, and family) who can help them evaluate the pros and cons of your proposal and the alternatives? Try to negotiate a solution that works for everyone while avoiding, or at least minimizing, any impact on people’s ability to fully exercise and enjoy all of their rights.

If you still feel that you must proceed to a Rights Modification, this form should reflect that you had a robust conversation and thought process leading you to that point. The process is much more than simply filling out this form: the form just summarizes information showing that the overall process was thorough and appropriate.

In this situation, providers may fill in information relating to items 1 through 6, reflecting their conversations and history with the individual, before giving the form to the case manager. The case manager must carefully review the information provided and discuss it with the individual (and their guardian/other legally authorized representative, if applicable), making sure that it fully explains what the individual needs to know to make an informed decision. In the course of this discussion, the individual and the case manager may modify the information on the form or initiate a different approach on a fresh form. After they have finished modifying/completing the form, they should sign at the bottom or sign electronically. Only the case manager may obtain these signatures.

 Additional guidance for completing the form:

•  This document should clearly, thoroughly, and respectfully explain all elements for the individual, so they can make an informed decision about signing.

• Use plain language, addressed directly to the individual, as this is a document for their review and consideration.

• As a part of ensuring plain language, there is generally no need to cite statutes or regulations or to use legal terms of art. This information certainly can be given by the provider or case manager, if the individual or guardian would like these references.

Before making a decision, please know:

• You have the right to get all of your questions and concerns answered. You can talk to advocates, peers, people who help you with supported decision-making, friends, family, and others. Feel free to have these conversations on your own or to ask your staff or your case manager to help set up these conversations.

• Your case manager can assist you, if desired, to connect with an independent advocate who is not involved with the services you receive.

• You should talk to your case manager to be sure you understand the proposed Rights Modification and the other information in this form.

• You can include anyone you want in these conversations.

• You can write on and alter this form to be sure you agree with it before you sign it. Your case manager can help if you want to propose changes.

• If you agree to this Rights Modification, you will review that decision and the information supporting it with your case manager, and others of your choosing, at least every year. This review can be sooner if you or others would like to consider changes at any time.

• If you agree now but change your mind later, you have the right to withdraw your consent.

• You will not be subject to retaliation or prejudice, with your services and supports, for declining to consent or for withdrawing your consent to this Rights Modification.