Private Organization Accreditation

Northside Psychological Services is a combination of both private practice and community mental health provider. We provide services to children and adults (EAP, private insurance, private pay, etc.) in our private practice setting. In our Community Care Program, we provide services to children and adolescents in their homes.


Bonnie Bagley

Volunteer Roles: Evaluator; Lead Evaluator; Peer Reviewer; Team Leader

I have found that being a COA Volunteer builds my professional skills and experience in ways that more traditional workshops do not. The opportunity to learn about best practices through the COA standards and then see how agencies implement them is truly a growth experience.
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The rights and dignity of clients are respected throughout the agency.

PA-CR 1: Protection of Rights and Ethical Obligations

The agency protects the legal and ethical rights of all clients by:

  1. informing clients of their rights and responsibilities;
  2. providing fair and equitable treatment; and
  3. providing clients with sufficient information for them to make an informed choice about using the agency and its services.

Interpretation: Although mandated clients may be required to attend a program, they should still have the right to refuse particular aspects of service or treatment unless mandated by law or court order, as addressed in CR 1.07.

Interpretation: Individuals receiving Adult Guardianship (PA-AG) services should retain as much personal responsibility and self-determination as possible given their assessed capacity, the court order, and state law. Refer to PA-AG for more information on appropriately involving the client in decision-making.

Rating Indicators
Full Implementation, Outstanding Performance
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.  
  • All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance. 
Substantial Implementation, Good Performance
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
  • The majority of the standards requirements have been met and the basic framework required by the standard has been implemented. 
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
Partial Implementation, Concerning Performance
  • A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.  
  • The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.  
  • Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.  
  • Service quality or agency functioning may be compromised.  
  • Capacity is at a basic level.
Unsatisfactory Implementation or Performance
  • A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.  
  • The agency’s observed administration and management infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
Please see Rating Guidance for additional rating examples. 

Table of Evidence

Self-Study Evidence On-Site Evidence On-Site Activities
    County/Municipality Administered Agency, State Administered Agency (Central Office), or other Public Entity
    • Client rights policy and procedures
    • Rights and responsibilities document provided to individuals and families at initial contact
    • Policy for providing services to minors without the consent of the parent or legal guardian
    • A description of the resources available to the agency to accommodate oral and written communication and language needs, as well as the visual, auditory, linguistic, and motor abilities of persons served
    • Schedule of fees, if applicable
    State Administered Agency (Regional Office)
    • List of regional resources for accommodating oral and written communication needs and language needs that are prevalent in the region
    • Schedule of fees, if applicable
No On-Site Evidence
    All Agencies
    • Interview:
      1. Relevant personnel
      2. Individuals or families served
    • Review case records
    • Facility observation

  • PA-CR 1.01

    At initial contact clients receive and are helped to understand a written summary of their rights and responsibilities, including:

    1. a description of the client’s rights, including the obligations the agency has to the client;
    2. basic expectations for use of the agency’s services;
    3. hours that services are available;
    4. rules, expectations, and other factors that can result in discharge or termination of services; and
    5. a clear explanation of how to lodge complaints, grievances, or appeals.

    Interpretation: If a client is disoriented, suffering from impaired cognition, or in immediate crisis at initial contact, the summary of client rights and responsibilities should be provided at an appropriate time. When working with individuals who have been deemed incapacitated by the court, the depth or content of information provided may vary based on the individual’s assessed capacity to understand the information, the court order, and state law.

    Interpretation: The agency’s explanation of how to lodge complaints, grievances, or appeals should include informing clients about their right to file a complaint with the appropriate public authority or regulatory body.

    Interpretation: For networks, when the scope of a network’s services includes service authorization and placement decisions, the client’s right to appeal placement and authorization decisions are outlined in written network client rights and responsibilities material available to clients, and in the provider manual or other document outlining network operational procedures.

    Interpretation: Agencies that use web-based technologies, telephonic, or electronic communications to deliver services shall implement a system for assuring and documenting that clients receive and understand their rights and responsibilities.

  • PA-CR 1.02

    A written summary of client rights and their responsibilities is posted in the reception areas of all service delivery locations.

    Interpretation: Affiliates who deliver services on behalf of an EAP are not required to post client rights and responsibilities in the reception area of their service delivery location, but clients must receive a written or electronic version upon service initiation.

    Note: Please see Facility Observation Checklist - Private, Public, Canadian for additional assistance with this standard.

  • FP
    PA-CR 1.03

    The agency states in writing circumstances under which it will serve minors without the consent of the parent or legal guardian and provides this information upon request.

    NA The agency does not serve minors without consent from a parent or legal guardian.

  • PA-CR 1.04

    Clients are informed of their responsibility to provide relevant information as a basis for receiving service and participating in service decisions.

    NA The agency provides Adult Guardianship only.

  • FP
    PA-CR 1.05

    Clients have the right to fair and equitable treatment, including:

    1. the right to receive services in a non-discriminatory manner; 
    2. the consistent enforcement of program rules and expectations; and
    3. the right to receive services that are respectful of, and responsive to, cultural and linguistic differences. 

    Interpretation: Fair and equitable treatment includes the provision of effective, equitable, understandable, and respectful services that are responsive to: diverse cultural beliefs and practices, including the freedom to express and practice religious and spiritual beliefs; preferred languages; and other communication needs. 

    Agencies’ policies, procedures, and practices should recognize, respect, and respond to the unique, culturally-defined needs of persons and families being served. For example, program information, signs, posters, and other printed material, as well as electronic and multimedia communications and training are available and presented: 

    1. in the language(s) of the major population groups served; and 
    2. in a manner that is non-discriminatory and non-stigmatizing.

  • PA-CR 1.06

    The agency accommodates the written and oral communication needs of clients by:

    1. communicating, in writing and orally, in the languages of the major population groups served;
    2. providing, or arranging for, bilingual personnel or translators or arranging for the use of communication technology, as needed;
    3. providing telephone amplification, sign language services, or other communication methods for deaf or hearing impaired persons;
    4. providing, or arranging for, communication assistance for persons with special needs who have difficulty making their service needs known; and
    5. considering the person’s literacy level.

    Interpretation: Basic program information is available in languages representative of consumer groups. Agencies that fully implement PA-CR 1.06 proactively reach out to ensure that all individuals can use its services and fully participate in planning. The agency has sufficient numbers of bilingual personnel for all programs in which confidential interpersonal communication is necessary for adequate service delivery. There is a bilingual worker on staff for each language group large enough to comprise an average-sized caseload. Trained translators or interpreters are available in other instances or in non-counseling services when bilingual personnel are not available. Assistive technology, such as amplification for hearing-impaired persons or a language telephone line, is used when appropriate.

  • FP
    PA-CR 1.07

    Clients participate in all service decisions and have the right to:

    1. receive service in a manner that is non-coercive and that protects the person’s right to self-determination;
    2. participate in decisions regarding the services provided;
    3. request a review of their care, treatment, and service plan;
    4. refuse any service, treatment, or medication, unless mandated by law or court order; and
    5. be informed about the consequences of such refusal, which can include discharge.

    Interpretation: When the client is a minor, or an adult under the care of a guardian, the agency follows applicable laws or regulations governing the right of the parent or legal guardian to refuse service, treatment, or medication unless mandated by law or court order. Adult guardianship workers should refer to the court order and state law when determining an appropriate level of involvement for each service recipient. See PA-AG 8 for more information on including the client in service decisions.

  • PA-CR 1.08

    Clients receive a schedule of any applicable fees and estimated or actual expenses, and are informed prior to service delivery about:

    1. the amount that will be charged;
    2. when fees or co-payments are charged, changed, refunded, waived, or reduced;
    3. the manner and timing of payment; and
    4. the consequences of nonpayment.

    Interpretation: When working with individuals who have been deemed incapacitated by the court, the depth or content of information provided may vary based on the individual’s assessed capacity to understand such information, the court order, and state law.

    NA The agency does not charge a fee for services.

  • FP
    PA-CR 1.09

    The agency designs and adapts its programs and services, as appropriate, to accommodate the visual, auditory, linguistic, and motor abilities of persons served.

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