Personal Data Form

 

The education course you are attending will give you the opportunity to learn new information and better understand different aspects of your behavior.  In order to ensure smooth classroom functioning and to enable all participants to gain the most benefits from the course,

 

Participants in the program are expected to:

 

·       Participate in group discussions.

·       Express opinions and feelings in a way that does not disrupt the class.

·       Attend all course sessions in their proper sequence.

·       Return from breaks on time.

·       Cell Phones must be left in your vehicle or placed on instructor table.  We are responsible for protecting your confidentiality.  Those who do not comply with the cell phone policy will be dismissed from class and no refund will be made.

·       No use of tobacco products during this class.  Law requires you remain no less than 25 feet from building entrance if you smoke before class, during breaks or after class.

·       Abstain from the use of ALL mood-altering chemicals from now until completion of the program.

·       No visitors allowed in class.

 

I understand that if in the opinion of the instructor I am disruptive or violate any of this agreement, I will leave immediately when asked to leave class.  The court or probation will be notified. 

 I understand that such disclosure will be limited to the following specific types of information:

1.       Information concerning general progress while in Access 2 Recovery programs;

2.       Counselor’s reports of attendance, participation and prognosis;

3.       Information contained in written records submitted by myself;

4.       General demographic and  academic information;

5.       Indications of active alcohol or other drug use;

6.       Admission and discharge dates including associated reports

7.       Other:___________________________________________________________

I understand this consent will remain in effect for two (2) years from the date of signature below.