CLIENT CONSENT
Are you answering for your child as a caregiver or family member? This form was designed for adults (persons 18 years or older) responding for themselves. If that's not you, please ask your provider for the form for caregivers/family members or for youth (12-17 years old).
What is this form about?
The Substance Abuse Mental Health Services Administration (SAMHSA) funds part of your behavioral health services. SAMHSA collects this information to monitor and improve services in your community and across the nation. Your response to these questions will help SAMHSA and your provider.
How is my information used?
SAMHSA does not collect your name or information that can identify you. The Privacy Act of 1974, 5 U.S.C § 552a, also requires SAMHSA to protect the privacy of your information.
SAMHSA collects this information from all persons served. SAMHSA looks for trends or patterns in the data.
SAMHSA combines information collected to see if services need to be improved.
Do I have to fill in this form?
No. You do not have to fill in this form. This will not result in any loss of services or benefits. If you choose to participate, you may:
*skip questions you do not want to answer.
*stop filling in the form at any time.
How long does it take to fill in the form?
*It should take you about 15 minutes.
How do I agree to participate?
By answering the following questions, you are agreeing to participate.