Conditions Of Return And Or Continuation Of Esnj Services

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Easter Seals
Feel Good About Giving
New Jersey
Telephone:
FAX:
Conditions of Return and/or Continuation of ESNJ Services
I ____________________, have received a copy of ESNJ’s Participant Manual and the manual
has been reviewed with me. I understand the information that is outlined in the Participant
Manual and any questions that I had about the manual, has been explained to me. I know that I
could be discharged from ESNJ services if, I jeopardize my own or someone else’s safety, or for
failure to follow Easter Seals rules. I understand that a future violation would result in discharge
from Easter Seals for not complying with any of the following rules:
Posing a threat to other people in the service (participants, staff and visitors).
Become disruptive to others or disruptive to the general work climate.
Not participating in my individual service plan.
Not coming to work on scheduled days
Starting fights (physical contact).
Stealing property of Easter Seals, coworkers or staff.
Willingly break property belonging to ESNJ, participants, or staff.
Smoking in a no smoking area.
Bringing, using, or being under the influence of illegal drugs or alcohol.
Following the general guidelines and ESNJ policies.
Following all safety guidelines.
It may also be recommended, that I agree to meet for psychological counseling once a week
following a Psychiatric Evaluation, if it is deemed necessary. I understand that, refusal to attend
scheduled counseling sessions would also be a violation of the condition of return and
continuation of ESNJ services and would result in discharge from program.
I
, am aware of the rules as outlined in the Easter Seals Participant
Manual and understand that I am expected to follow these rules. I also know that any
future violation of the above conditions would result in discharge from Easter Seals NJ
Employment Services.
Referred for counseling:
Yes
No
Initials: _________
Referred for psychiatric evaluation:
Yes
No
Initials: _________
.
.
Participant signature
Date
Parent/Guardian
Date
.
.
Service Specialist
Date
Site Director
Date
Easter Seals New Jersey is committed to helping children, adults and families with disabilities and special needs
live, work and play in their communities with equality, dignity and independence.

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