Number    Number of times married

I, blanks * authorize Hope House, Inc. to contact the following people in the event of a medical emergency.

Estimated Annual Household Income - may be used for sliding fee scale and for general demographic purposes (aggregate)
   Please Select $0 - $15,960$15,961 - $33,000$33,001 - $45,000$45,001 - $60,000$60,001 - $100,000Above $100,000Court Ordered Indigent StatusOtherDecline to Answer * $0            

First Name *     Last Name *    

I, name of client * authorize Hope House, Inc. to release to Name of person or organization * the following information: Diagnosis, placement, attendance, treatment plan, and discharge. The purpose of the disclosure authorized in this consent is coordination of care during my outpatient treatment.

I understand that my alcohol/drug treatment records are protected under the federal regulation governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42, C.F.R., Part 2 and the Hearth Insurance Portability and Accountability Act of 1996 (HIPPA), 45 C.F.R., Parts 160 and 164 and cannot be disclosed without my written consent at any time except to the extent that action has been taken in reliance on it, and that in any event this consent expires automatically one year from the date this consent is signed and dated (for example: a release signed and dated January 1, 2021 will expire January 1, 2022).

I understand that I might be denied services if I refuse to consent to a disclosure for purposes of treatment, payment, or health care operations, if permitted by state law. I will not be denied services if I refuse to consent to a disclosure for other purposes.

Date *     Sign with FULL LEGAL FIRST, MIDDLE AND LAST NAME WITH STYLUS OR FINGER *    

Date *     First Name *     Last Name *    

The results of the UNCOPE or CRAFFT screening have been explained to me by Hope House staff.
I,    First Name *     Last Name *    , agree to continue with the ASAM Assessment.

Sign with FULL LEGAL FIRST, MIDDLE AND LAST NAME WITH STYLUS OR FINGER *        Date *    

I do not have any involvement in the Criminal Justice system.       

I,    First Name *     Last Name *    , authorized Hope House, Inc. to communicate with:
The name of Probation/Parole Department and employee supervising my case *    
Name of Judge and appropriate court *    
Other    
and disclose to one another the following information:
my diagnosis, urinalysis results, information about my attendance or lack of attendance at treatment sessions, my cooperation with the treatment program, prognosis, and
Other    

The purpose of this disclosure is to inform the person(s) listed above of my attendance and progress in treatment.

I understand that my alcohol and/or drug treatment records are protected under the federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 C.F.R. Parts 160 and 164. I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it, and that in any event this consent expires automatically as follows:
Specify the date, event, or condition upon which this consent expires. This could be one of the following:
-there has been a formal and effective termination or revocation of my release from confinement, probation, or parole, or other proceeding upon which I was mandated into treatment or
Specify one year from registration *    

I understand that I might be denied services if I refuse to consent to a disclosure for purposes of treatment, payment, or health care operations, if permitted by state law. I will not be denied services if I refuse to consent to a disclosure for other purposes. I further understand that if I revoke this release form the court may otherwise terminate me from the criminal justice program.

Date *        Signature Full LEGAL FIRST, MIDDLE AND LAST NAME WITH STYLUS OR FINGER *    

   

Understanding that certain rules and requirements are essential to the treatment process and to my recovery, I agree to the following commitments during my participation in the Hope House program:
 
1. I agree and understand not to discuss the names, subjects, conversations or situations that I observe in Hope House facilities or shared in the group process. I understand that it is against Federal Law to break the confidentiality of any client at Hope House.
2. I agree not to use mood-altering drugs, including alcohol, street drugs, over-the-counter drugs, (including but not limited to CBD Products, Tiana, AddAll etc.) or any prescription drugs not prescribed to me.
3. I agree and understand that the length of my substance treatment is determined by my progress or lack thereof, not by my Referring Agency.  Lack of participation, lack of cooperation or inability to maintain abstinence may negatively affect my recovery or cause me to be discharged from the program according to Alabama Department of Mental Health guidelines.
4. I agree and understand that I will attend a minimum of 1 group/individual session per week and 1 self-help meeting per week. A list of Self-help meetings can be found on the additional resources page of the Client Handbook which will be provided to me at the time of registration.
5. If my referral source requires a specified number of self-help meetings, then I must adhere to their requirements in addition to Hope House's recommendation.
6. I agree to attending regularly and being punctual to the sessions to which I am assigned. If I arrive more than 10 minutes late, I will not be allowed to attend any session unless prior notice is given to the counselor and the counselor approves the tardiness. Absences and tardiness may result in sanctions (as determined by the Referring Agency) or termination from the program (based on treatment team recommendations).
7. I agree to participate in group activities and to be courteous and understanding in my interactions with other group members and participants. This includes not using profanity, being respectful to staff and other clients, and waiting my turn to speak.
8. I agree to submit to voluntary drug screens upon request of Hope House Staff in an effort to support the integrity of the program and verify my commitment to sobriety. I also agree to maintain my participation in the color code drug testing program and understand a missed drug test/dilute is considered a positive result. Positive drug screens may result in consequences from the referring agency or a recommendation for a more intensive level of care from Hope House treatment team.
9. I understand that cell phones must be turned off. At no time may pictures or recordings be made on the premises. 
10. I understand that smoking is only allowed off the premises. No chewing tobacco, snuff, or e-cigarettes (including vapes) are to be used inside the buildings or on campus.
11. I understand that no client is to be in any office without a staff member present and that no client is to use office phones without a staff member present.
12. I understand that children and pets are not allowed unless approved by treatment team.
13. I understand that other rules may be added by the clinical staff as necessary for order and safety.
14. I understand that violations of these rules may result in: removal from group, probationary periods, report to the referral source, and/or discharge from the program.
15. I understand that my referring agency will receive my letter of completion after all outstanding administrative, rescheduling and individual/group fees have been paid per the referring agency’s agreement with me. 
16.  I understand that my therapist is a mandatory reporter and if it is determined that I am a risk
to myself or others, it will be reported to the appropriate agency.

Date *        Signature of FULL LEGAL FIRST, MIDDLE and LAST NAME with stylus or finger *    

I,    First Name *     Last Name *    , affirm that I participated in the UNCOPE or CRAFFT screening and ASAM Placement Assessment. I further acknowledge that my treatment recommendations have been clearly explained to me, and I have been provided the opportunity to decline the treatment recommendation. Additionally, information regarding alternative treatment options that could meet my needs has been provided.

1. I understand that the laws that protect the privacy and confidentiality of medical information also apply to telehealth, and that no information obtained in the use of telehealth which identifies me will be disclosed without my prior permission, except in medical emergencies, research or audits.

2. I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, except to the extent that it has already been acted upon; and that this will not affect my right to future care or treatment.

3. I understand that my Therapist wishes me to engage in a telehealth consult and I am in agreement that this may possibly benefit me.

4. I understand technical obstacles may occur which could interrupt or terminate the ability to perform the service.

5. I agree to be in a location that affords privacy. Any breech of privacy on my end, due to location or Internet platform is my responsibility and not that of the Center or the Therapist.

6. I have had the alternatives to a telehealth consult explained to me and am choosing to participate in a telehealth consultation.


By signing this form I certify:

- That I have read this form and or had this form explained to me.

- That I fully understand its contents including the risks and benefits of the procedure(s).

- That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction. 

   Signature of FULL LEGAL FIRST, MIDDLE, and LAST NAME with stylus or finger *     Date *