Division of Child and Family Services

DIVISION OF CHILD AND FAMILY SERVICES

Report of Denial of Rights for Clients/Patients with Mental Illness

Case # ______

Assigned by DCFS Staff Only

TO:

DCFS Division Administrator (DCFS agencies only) ______

Facility Director (Signature indicates review only) ______

Name of Facility: ____________

Date of Incident: ______Time of Incident: ______

Client’s/Patient’s age: ______

Admission Date: ______

Reporting Staff: (Print full name and title): ______

Reporting Staff Signature: _______

Legal Mandate: Per NRS 433.454 and NRS 433B.350 a client’s rights must not be denied unless that client has a mental illness AND is a danger to the health and safety of themselves or others.

This client has a mental illness and is a danger to the health and safety of: Self Others

Right has been denied/restricted: OR The facility intends to deny/restrict right:

The facility has denied or intends to deny/restrict this client’s right to:

Refuse treatment other than medication (client refuses/unable to provide consent for treatment, sign plan)

Have information remain confidential (specify)______

Have visitors each day (specify)______

Make/receive confidential phone calls (specify) ______

Keep personal possessions/wear own clothing (specify) ______

Other (Describe and use DCFS Policy # ______, if applicable)______

______

Describe the specific behavior of the client receiving services that is leading to this denial: ______

______

Indicate what interventions staff used to prevent the need for this denial:

(Check all that apply)

1/1 counseling PRN medication Time out Reduction in stimuli

Vent feelings Other; describe: ______

______

Witness(s) to denial incident (full name and title): ______

______

Person receiving services (Name): ______

Facility Case Number: ______

DO NOT WRITE BELOW THIS LINE – COMMISSION ON MENTAL HEALTH AND DEVELOPMENTAL SERVICES USE ONLY

Sp-6 Medication Admin and Management Policy

Attachment F – Report of Denial of Rights Form REV: 01-13