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.

Carefully read and complete modules EXACTLY as stated in your workbook.  After presentation and counselor approval, you may continue to the next module; if not approved you will present at the next group.  DO NOT work ahead.  If/when you do, your workbook will be confiscated and you will be required to start over with a new workbook and a $25 charge for the purchase of the new workbook.  This may extend your number of weeks in this program.

 

You must bring your workbook to every session in order to present.

 

Participate in group discussions. 

 

Express opinions and feelings in a way that does not disrupt the session.  Be attentive and respectful when others are expressing their opinions.

 

Keep all sessions confidential; failure to maintain confidentiality is cause for non compliant discharge. 

 

Be on time, late arrivals may be treated as an absence.

 

Attendance at every session is expected.  Module presentation will not be allowed if arrival is more than 5 minutes after group starts.  You will be discharged if you have three absences in a row.  Three absences are allowed during the duration of the program.  You will be immediately discharged from the program if a fourth absence occurs.  If discharged you will be required to start the program over at week one.  If your probation requirements do not allow you to be absent from group then this policy does not apply to you.

 

The program is 12 weeks at a cost of $25.00 per week.  Stay current with session payments.  You cannot present your module if you are not current with session fees.  Overpayment will be carried forward on account. 

 

Cell Phones and cameras and recording devices are prohibited.  Leave your phone in your vehicle or turn it off and place on instructor table when you enter the building.  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. 

 

Submit to random drug/alcohol screening.  A positive screen will result in a charge of $20.  A substance abuse evaluation will be required and recommendations completed before re-admittance in the Anger Management Program.  Refusal to submit to a random drug/alcohol screen will be considered a positive finding and will result in immediate discharge.  The court and probation will be notified. 

 

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.