Client Agreement/Information Release Form

Client Agreement

I request to become a client of Crossroads Ministry of Estes Park, and I agree to the following:

1. I understand that I am entitled to be treated with dignity, respect and courtesy by every employee and volunteer at Crossroads Ministry.

2. I agree to treat every employee and volunteer of Crossroads Ministry with dignity, respect and courtesy.

3. I understand that I am entitled to nothing from Crossroads Ministry, and that the ministry is not required to meet any of my requests.

4. I will be truthful, honest and complete in answering all questions on the Crossroads Ministry Client Information Sheet and will notify Crossroads Ministry of any changes.

5. I understand that I am not allowed to authorize any person living outside my household to seek services in my name.

6. I understand that if any Crossroads Ministry employee or volunteer deems that I am under the
influence of any substance that services will be denied to me at that time.

7. I understand that Crossroads Ministry’s staff has a responsibility to call appropriate law enforcement authorities if I attempt to drive off the premises while under the influence of drugs and/or alcohol.

8. I understand that Crossroads Ministry’s staff has a responsibility to report any suspected occurrence of child abuse, child neglect, elderly abuse or elderly neglect to the appropriate authorities.

9. I understand that Crossroads Ministry’s staff has a responsibility to contact local law enforcement authorities if I make any threat to do harm to myself or another individual.

10. I understand that I have a responsibility to provide all requested information and documentation in a timely manner.

11. I understand that some of the food products I receive are perishable and require refrigeration, and that if I fail to refrigerate or prepare the food properly, Crossroads Ministry is not responsible.

I agree and understand that it is my duty to comply with all parts of this agreement. I also understand that my failure to comply with this agreement could result in the termination of all services I receive from Crossroads Ministry.