Consent Form Client's Name Street Address State City Zip By this document, I give consent to Community Support Solutions to provide DDA supported CFC/MPC, RESPITE CARE and IN HOME CARE services to the following individual:Indicate the name of Care recipient I have received the Patients Bill of Rights, the Grievance Policies and Procedures and the Advanced Directives Policy provided by Community Support Solutions. I understand that I am responsible for any charges not covered by Medicaid or Developmental Disabilities Administration.* Agreed to the PoliciesI have received the Patients Bill of Rights, the Grievance Policies and Procedures and the Advanced Directives Policy provided by Community Support Solutions. I understand that I am responsible for any charges not covered by Medicaid or Developmental Disabilities Administration. Client's Signature*Relationship to Client (if not the client) Client Intake Completion Date* MM slash DD slash YYYY Δ