Client Orientation Form

NOBLE COUNTY PROBATION DEPARTMENT
NOBLE COUNTY COURT SERVICES CLIENT ORIENTATION
Name

First NameLast Name
HAVE BEEN GIVEN A COPY OF EACH ITEM BELOW AND HAVE HAD EACH EXPLAINED TO ME BY THE STAFF OF NOBLE COUNTY COURT SERVICES ALCOHOL AND DRUG PROGRAM.

MY INITIALS ON EACH LINE AND MY SIGNATURE BELOW ACKNOWLEDGES CONSENT TO RECEIVE SERVICES.
a.) HOURS DURING WHICH SERVICES ARE PROVIDED*
b). PHILOSOPHY AND PURPOSE OF THE PROGRAM.*
c). PROGRAM GOALS OF PROVIDED SERVICES.*
d). FINANCIAL ARRANGEMENTS.*
e). RULES AND DISCIPLINARY ACTIONS.*
f). PROGRAM EXPECTATIONS OF CLIENT.*
g). SCHEDULE OF FEES.*
a). CLIENT RIGHTS (UNCONDITIONAL 440 IAC 2 3 21 AND CONDITIONAL 440 IAC 2 3 21).*
b). CONFIDENTIALITY.*
c). CONSENT TO RECEIVE SERVICES.*
d). GRIEVENCE PROCESS.*
e. NON DISCRIMINATION*
CLIENT SIGNATURE*

Clear
DATE*

MonthDayYear
Date
GUARDIAN
If applicable
Date

MonthDayYear
If applicable
**INFORMATION CONCERNING CONFIDENTIALITY OF ALCOHOL AND DRUG ABUSE CLIENTS ARE POSTED IN THE WAITING ROOM.
Should be Empty:

NOBLE COUNTY PROBATION DEPARTMENT