Wellness Contract and Plan of Care

January 16, 2024

Fred Victor Respite Services is a program that supports and assists program participants in achieving their
goal of self-sufficient independent living. Fred Victor Respite Staff will continue to support you as you
continue to work towards your identified goal(s).

During your stay in the program, staff have addressed with you the concerns of successfully maintaining
and holding your bed space and following FTR guidelines.

However, we (staff) want to continue to serve and support you. We have agreed to keep you in the
program based on your agreement to establish a contract. However, failure to comply with the terms of
the contract will result in automatic discharge from the program to a better-suited program.

I, Robert Cronin, understand that Fred Victor Respite Services is a safe environment for everyone who
resides here. In order to ensure that I abide by both my rights and responsibilities during my stay at the
Respite I agree to the following terms and conditions:

 I will comply with the Failure To Return (FTR) guidelines and policy.
 I will not miss bed checks unless an emergency occurs.
 I will comply with staff and Fred Victor 24 HR Respite directives to successfully maintain
my bed here.

I am aware that this agreement is effective with or without my signature. In addition, this contract
agreement is effective immediately and will stay in effect until further notice.

Client Signature: _________________________ Staff Name: ______________________________

Date: ___________________________________ Date: _____________________________________