Rocvale Children's Home

Milestone, Inc.

CONSENT FOR USE OF PHYSICAL RESTRICTION

I, , Parent/Guardian of ,

(Parent/Guardian) (Individual)

having been informed of the definition and use of physical restriction, namely an arm wrap, do herein authorize its use when necessary for the individual to ensure his/her safety or the safety of others.

This authorization will also be documented in the individual’s file and will be done only when it is part of a written behavior program and used in conjunction with positive reinforcement.

Definition:

An arm wrap is a physical restriction, which consists of a staff member(s) using the minimum amount of pressure necessary to prevent injury to self or others. The physical restriction consists of one staff member standing/sitting behind and holding the individual's arms in a crossed manner across the front of the chest and held for no longer than one minute increments.

The release is valid for no more than one year after date signed. I understand that I have the right to rescind this consent at any time by submitting such request in writing to the Executive Director.

I understand that I have the right to be informed of each instance of physical restriction.

(Initial one below)

I do not wish to be notified every time my child is placed in an arm wrap.

I wish to be notified every time my child is placed in an arm wrap. I wish to receive this information (initial one):

Daily, Weekly, Monthly, , Annually

I understand that the consequences of my refusal to consent would be that, if the individual presents a danger to self or others, he/she will be placed in an arm wrap and I may not be notified of the physical restriction (arm wrap).

I understand and intend that copies of this original carry the same power as the original.

Parent/Guardian Signature Date

Witness Signature Date

SS. 38-RV Rev. 10/13