Resident Rights Acknowledgment
Professional Resident Rights Acknowledgment template for Adult Family Homes. Includes editable Word (.docx) and printable PDF formats.
[YOUR ADULT FAMILY HOME NAME HERE]
Resident Rights Acknowledgment
TEMPLATE • Inspection-Ready AFH Standard
1. Statement of Resident Dignity & Autonomy
This agreement is entered into on this _____ day of ____________, 20___, between [ADULT FAMILY HOME NAME] (Provider) and [RESIDENT / POA NAME].
2. Communication & Freedom of Access Rights
FINANCIAL TERMSBase Rate & Payment Schedule: Resident agrees to pay Provider a monthly base fee of $______ payable in advance on the first (1st) day of each calendar month.
3. Financial & Personal Property Protections
Provider Signature / Date
Resident / POA Signature / Date
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Document Section Breakdown (3 Sections)
Statement of Resident Dignity & Autonomy
Fundamental guarantees of privacy, self-determination, and respectful care.
Communication & Freedom of Access Rights
Phone, mail, visitation, and healthcare provider choice guarantees.
Financial & Personal Property Protections
Safekeeping of funds, personal belongings, and protection from financial exploitation.
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