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.

Should I return to using non-prescribed, mood altering chemicals or drink alcohol during my counseling process I understand and agree that the clinical staff may recommend a more intensive level of care.  I also agree to random drug screens at the discretion of the clinical staff.  I understand that an unwillingness to submit to a breath or urine test will be interpreted as a clear indicator that I have been using mood-altering chemicals or drinking alcohol, and I will be charged $20.00, this fee also applies if I test positive for any mood-altering chemical including alcohol.

I will consult Access 2 Recovery staff regarding any medications prescribed to me by a physician.

ABSENCES

ABSENCES

For the duration of the program, I understand that I will be discharged unsuccessfully from the program should I be absent from more than three (3) group session or three (3) group sessions in a row.  I understand that the program is 13 weeks minimum including intake.  In order to complete the program I must be in attendance and compliant with the program rules for all group session, successfully complete all assignments and activities, and attend any scheduled individual appointments. 

 

I understand that the weekly fee of $25.00 is to be paid at the beginning of each session.  I understand there is a one-time $60.00 intake fee due at the first session.   

 

Should I become seriously ill, incarcerated, or otherwise prevented from attending group sessions or individual appointments, I understand that I can be placed on inactive status, contingent upon my providing proper documentation. 

 

I understand that if I am discharged from the program for a positive drug screen or breath test, I will obtain a substance abuse evaluation and follow the recommendations prior to being readmitted to the program.  I understand if I am discharged from the program due to absences or disruptive behaviors I can re-enroll one time.

 

I am willing to complete the program as it has been outlined to me and to participate in the sessions without becoming resistant or disruptive.

 

 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.