THERAPEUTIC CONTRACT

Name*

First NameMiddle NameLast Name

Date

As a Client in the Miami Valley Recovery Substance Use Disorder Program, I freely and voluntarily agree to accept this treatment contract as follows:

I understand that MVR is an outpatient treatment program that is a combination of groups, individuals, family sessions (when appropriate), random urine screens, medication therapy and medication counts. I agree to participate in all aspects of programming.*

YESNO

I am expected to be respectful of myself, peers and staff while in attendance at MVR.*

YESNO

I agree not to arrive at the office intoxicated or under the influence of drugs. If I do, the staff will not be able to see me.*

YESNO

I agree to provide a urine upon arrival at MVR prior to participating in any other treatment services.*

YESNO

I am required to attend group sessions, individual sessions, family sessions and medical visits as defined in my treatment plan. I am responsible to schedule all appointments with the front desk or with my counselor. Once scheduled it is my responsibility to attend all appointments and to be on time. My attendance is crucial. Missed appointments or tardiness will negatively impact my therapeutic relationship. This is how Miami Valley Recovery is able to provide appropriate treatment and assure my medication is working correctly. In addition, insurance companies request attendance as well as progress and urinalysis reports so compliance is essential for your treatment, medication approval and insurance reimbursement.*

YESNO

On the rare occasion I might need to reschedule an appointment it is my responsibility to give a minimum of 24 hour notice. (This includes all appointments regardless of type.) This is a respect issue for myself, peers, and staff at MVR. Since compliance is mandatory it is important to realize I might not be able to reschedule for that week. If this is an emergency situation I must bring legitimate validation explaining my absence.*

YESNO

Tardiness for counseling sessions or Physician/CNP/PA appointments is not acceptable and may result in an inability to be seen. Any unexcused missed groups, individuals, family sessions or Physician/CNP/PA visits will increase the frequency of sessions I am expected to attend and slow down my progress.*

YESNO

Failed drug screens, medication dosage increases (after I am established in treatment) or inaccurate med counts indicate a treatment need for additional individual and counseling sessions as well as increased medical visits with prescriber.*

YESNO

For my induction I want to detox from all mood altering substances for a period of 24 hours minimum prior to my first visit with the prescriber for medication. (Subutex is only prescribed for verified pregnancy.) This is to prevent me from going into a precipitated withdraw. More detail will be discussed in my assessment and again at my induction.*

YESNO

Women of childbearing potential - I agree to tell the Physician/CNP/PA if I become pregnant or even think I may be pregnant. I understand that I must submit to bimonthly pregnancy tests throughout the duration of the Program.*

YESNON/A

MVR is very conservative in the way we prescribe medication and the dose you will receive. We believe medication is only a part of your treatment serving as one of the many tools you will use here as you work on your recovery. (While in treatment you will get to develop your personal recovery tool box.)*

YESNO

I agree not to sell, share, or give any of my medication to another individual. I understand that such mishandling of my medication is a serious violation of this agreement and would result in my treatment being terminated without recourse for appeal.*

YESNO

I agree not to deal, steal, or conduct any other illegal or disruptive activities on the property of MVR.*

YESNO

I agree that my medication (or prescriptions) can provided for me only at my scheduled renewal times. Please do not call to request prescriptions be given prior to that time. Any noncompliance in treatment expectations will result in my not being able to get medication until following my next week of compliance.*

YESNO

My medication must be protected from theft or unauthorized use. I understand and agree that my medication must be stored safely, and securely where it cannot be taken accidentally by children, pets, or be stolen. If my medications are stolen, I will file a report with the police and bring a copy to my next visit. If another person ingests my medication, I will immediately call 911 or Poison Control at 1-800-222-1222. I agree to take full responsibility for the safekeeping of my medication. Lost or stolen medication will not be refilled before the date it was due to be renewed unless I can give the clinic a copy of the police report of the loss. I understand my Physician/CNP/PA reserves the right to refuse refills.*

YESNO

I agree not to obtain medications from any Physicians/CNP/PA, pharmacies or other sources without informing MVR. I understand that any time I seek medical/dental care elsewhere I want to let them know I am in recovery and using MAT.*

YESNO

I agree to take my medication as the Physician/CNP/PA has instructed and not to alter the way I take it without consulting MVR first. Disregarding instructions is considered abuse of my medication.*

YESNO

Client Signature *

Clear

Date

Staff Signature

Clear

Date