Family History

Describe your relationship with your:

By signing this form, I agree that the information I have provided is correct to the best of my knowledge.

The confidentiality of alcohol and drug abuse client records maintained by this program is protected by Federal law and regulations.  Generally, Prevention Education & Referral Services, Inc. may not say to a person outside the program that a client attends the program or disclose any information identifying a client as an alcohol or drug abuser UNLESS: 

1.  The client consents in writing; 
2.  The disclosure is allowed by a 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.  

Violation of Federal law and regulations by a program is a crime.  Suspected violators may be reported to appropriate authorities in accordance with Federal regulations.  

Federal law and regulations do not protect any information about a crime committed by a client either at the program or against any person who works for the program or about a threat to commit such a crime.  

Federal laws 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.

1. No alcohol or illicit drug use prior to or during classes or individual appointments. Suspicion of use will result in immediate dismissal from program.

2. Failure to attend scheduled appointment will result in a fee of up to $35 for reassignment.

3. No abusive and/or threatening behavior. If a facilitator feels a person’s behavior is detrimental, he/she may request that the client leave and refer the case to the Program Director for final disposition.

4. Use of telephone, tablet or other communication/electronic device is prohibited.  

5. In order to obtain a successful completion of program, you must complete the classes as you are scheduled.

6. You must participate in all scheduled activities of the program including exit interview when applicable.

7. Taking photographs, screen shots, or recording any portion of the program is prohibited.  Immediate discharge will occur if there is suspicion of such activity which results in a non-compliant discharge and reporting to probation officer. 

Failure to comply with the above mentioned rules may result in immediate discharge from the program. If your referral source is a court, please note the court will be notified and this could violate your probation and/or bond.

If you wish to appeal your discharge from the program, you shall contact the Program Director, who will review your case and make a determination. If you wish to further appeal the decision, contact the Program Rights Advisor.

I have been informed that I am not to use any alcohol or illicit drugs before or during classes, groups or individual appointments.

I am aware of what my responsibilities are as a client, the rules of the program, and what behavior/infractions could lead to my termination/discharge from the program.

I received a brief orientation to the program and are aware of the fee schedule, reassignment fee and absence policy.

I understand that failing to successfully complete the program as scheduled will result in immediate notification of my probation officer.

By signing below, I acknowledge that I understand the above mentioned rules.