Consent for AoD Treatment Fee Agreement Receipt of Forms

Consent for AoD Treatment Fee Agreement Receipt of Forms
Name*

First NameLast Name
Date*

MonthDayYear
Date
Substance Abuse Prevention/Resource Institute, LLC (SAPI) provides services to individuals and/or families who have substance abuse/chemical dependency problems. The staff members are trained to provide appropriate treatment/services as needed in this area.

I have read and understand the information regarding consent to AoD treatment/services, I have also received a copy of and understand the following:
Fee for Services:*
Program Rules:*

YesNo
Client Rights and Grievance Policies andProcedures*

YesNo
A Written Summary of the Federal Laws andRegulations Pertaining to the Confidentiality of Client Records and Required by42 CFR, Part 2*

YesNo
Education Material on Tuberculosis, Hepatitis Band C, and HIV/AIDS*

YesNo
I agree to treatment by the above mentionedagency rendering treatment/services.*

YesNo
Client Signature*

Clear
Staff Signature

Clear
Should be Empty: