Personal Data Form

I have received a detailed explanation of the treatment program that I am about to voluntarily enter so that as a client I understand:

 

1.      The specific condition to be treated;

2.      The recommended course of treatment;

3.      The expected benefits of the treatment;

4.      The probable health and mental health consequences of not consenting;

5.      The side effects and risks associated with the treatment;

6.      Any generally accepted alternatives and whether an alternative might be appropriate;

7.      The qualifications of the staff that will provide treatment;

8.      The name of the primary counselor;

9.      The client grievance procedure;

10.  The client bill of rights;

11.  The program rules;

12.  Violations that can lead to disciplinary action or discharge;

13.  Any consequences or searches used to enforce program rules;

14.  The estimated charges, including an explanation of any services that may be billed separately;

15.  The facility’s services and treatment process;

16.  Opportunities for family to be involved in treatment; and

17.  The expected length of stay.

  

I, {name} acknowledge that I have been explained this consent to treatment and understand that my signing gives Access 2 Recovery, LLC permission to treat me.

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 you must follow these program requirements:

Participants in the program are expected to:

·       Participate in group discussions, 1 to 1 sessions, and homework.

·       You may express your opinions in a way that does not disrupt the class.

·       Attend all course sessions in the proper sequence.

·       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.

·       You must bring a significant other (spouse, if married) to Module 9 and 10, Family Week.

·       You must be on time; late arrivals may be treated as an absence & Return from breaks on time. 

·       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.

·       You must ABSTAIN from the use of ALL mood-altering chemicals from now until completion of the program.

·       No visitors are allowed except during Family Week, Modules 9 and 10.

·       You will attend at least two AA meetings between Modules 11 and 12.

·       There will be a $20 fee for duplicate certificates of completion.

·       Absences:  

·        Must be cleared by the Instructor of the program prior to the absence

·        May result in being dropped from the program

·        Will be reported to the court and probation department

·       Makeup Sessions

·        Must be scheduled immediately by contacting the Instructor

·        Are the students responsibility and must be completed before the next session of the class

·        Fee for Makeup Session is $50 in addition to the session fee

·        No more than two absences if makeup’s are attended properly will be allowed

 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.