CONSENT

Except as otherwise authorized by law, written consent for admission to the program must be properly obtained as a condition for admission to the program, according to the guidelines outlined in the following section.

CONSENT ELEMENTS

The following information must be explained by a trained staff person to the client and other consenters, and documented in the client’s file(Exhibit A):

  1. The program’s services and treatment;

  2. The specific condition for which services will be received;

  3. The expected charges for services, including any charges that may be billed separately;

  4. The clients Rights and Responsibilities;

  5. The rights of the consenters to obtain information about the client’s treatment, etc.; and

  6. The procedures for complaint and question resolution.

Exhibit A

CONSENT TO RECEIVE SERVICES

I,___________________________________, have familiarized myself with

(Print Name)

Recovery Works services and treatment, its requirements and charges, and hereby give consent for such services as recommended by the Recovery Works program, rendered for the following specific conditions:

______________________________________________________________

(Specific Conditions)

The expected charges for services, including any that may be billed separately, have been explained to me.

I have been given a copy of client rights and responsibilities as well as information about the rights of consenters to obtain client information and have had such explained to me. I have also had the procedures for complaint and question resolution explained to me.

I hereby give my consent to have my belongings searched at random, for random urine drug screens to be conducted, as well as random Breathalyzer tests for the purpose of monitoring the recovery progress.

__________________________________________________________________________

Signature Date

__________________________________________________________________________

Staff Signature Date