CONSENT
FOR THE RELEASE OF CONFIDENTIAL INFORMATION
I, hereby authorize
to release to
for the purpose of
the following information:
I understand that my records are protected under the Federal and state
confidentiality regulations and cannot be disclosed without my written consent
unless otherwise provided for in the regulations. I also understand that I may
revoke this consent at any time except to the extent that action has been taken
in reliance on it (e.g., probation, parole, etc.), and that in any event this
consent expires automatically in 90 days unless otherwise specified below.
Other expiration specifications:
Date executed:
Signature of client:
Signature of witness:
CONFIDENTIALITY OF ALCOHOL AND DRUG ABUSE CLIENT RECORDS
The confidentiality
of alcohol and drug abuse client records maintained by this program is
protected by Federal law and regulations. Generally, the program may not say to
a person outside the program that a client attends the program or disclose any
information identifying a client as participating in an alcohol or drug abuse
program UNLESS-
1. the client consents in writing; or
2. the disclosure is required by court order; or
3. the disclosure is made to medical personnel in a medical
emergency or to qualified
personnel for research, audit, or program evaluation; or
4. the client commits or threatens to commit a crime either at the
program or against any
person who works for the program.
Violation of the Federal law and regulations by a program is a crime. Suspected
violations may be reported to the United States Attorney in the district where
the violation occurs.
Federal law and regulations do not protect any information about suspected
child abuse or neglect from being reported under state law to appropriate state
or local authorities.
I have read, understand, and received a copy of the above
statement.
Client signature Date
Witness signature Date
PRINCIPLES OF CONDUCT
As a client of this
program, you are expected to behave at all times in accordance with our
Principles of Conduct. If for any reason you fail to follow these principles,
you may be asked to leave the program so that your behavior does not become a
barrie to the recovery of others.
Our Principles of Conduct are as follows:
1. I will be honest about matters related to my recovery.
2. I will sincerely attempt to understand my addictions problem.
3. I will follow the directives and advice offered by the staff.
4. I will not use drugs or alcohol at any time during the program. (Clients
taking
prescribed medications will be allowed to participate in the program with the
approval of the Director.)
5. 1 will submit to breath tests or random urine drug screening or searches
when asked.
6. I will honor the confidentiality and rights of other clients, staff, and
volunteers.
7. I will be considerate and respectful of other clients, staff, and
volunteers.
8. I will not engage in or tolerate violence, threats of violence, and/or
antisocial
behavior.
9. I will not engage in sexual contact of any kind-physical or verbal-with
others in
the program, the staff, or volunteers.
10. I will be on time for all meetings and sessions assigned by my Counselor,
except
when excused for good reason in advance by the Director of the program.
11. I will not smoke during group sessions.
12. 1 will not eat or drink during group sessions.
The Principles of Conduct have been clearly read and explained to me. I have
been given a copy for my own use. My signature below is an acknowledgement that
I understand and agree to abide by these Principles of Conduct.
Client Signature and Date Staff Person Signature and Date
CLIENT RIGHTS
I . You have the right to treatment without regard to race,
religion, sex, ethnic back-
ground, age, sexual orientation, physical disability, employment
status, insurance
coverage, or any other nonclinical reason.
2. You have the right to professional, committed, and qualified
services.
3. You have the right to be informed about all program policies
which affect the course
of your treatment.
4. You have the right to confidentiality of your treatment record,
except in case of
medical emergency or court order.
S. You have the right to participate with your Counselor in your
treatment plan and in
other decisions that will establish your treatment goals.
6. You have the right, with specific limitations, to see your own
treatment record.
7. You have the right to be treated with dignity and respect.
8. You have the right to question any aspect of your treatment
experience.
You have the responsibility to protect your rights. If at any time you believe
your rights have been violated, please contact the Director of the program
immediately.
My rights have been clearly read and explained to me. I have been given a copy
for my own use. My signature below is an acknowledgement that I understand my
rights.
Client Signature and Date Staff Person Signature and Date
