Consent for Alcohol and Other Drugs Treatment

Consent for Alcohol and Other Drugs Treatment

Fee Agreement and Receipt of Forms
Name*

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Miami Valley Recovery LLC provides services to individuals and/or their families who have substance abuse and chemical dependency problems. The staff members are trained to provide appropriate treatment and services as needed in this area.

I have read and understand the information regarding consent to alcohol and other drug treatment and services. I have also received a copy and understand the following:
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I will pay the $375 Enrollment Fee (if applicable)Program Rules and Expectations – Therapeutic ContractClient Orientation Handbook-------A written summary of the Federal Laws and Regulations pertaining to the confidentiality of the clients records as required by 42 CFR Part B, Paragraph 2.22-------Education materials on tuberculosis, hepatitis B and C and HIV/AIDS------Advanced Directives------Client’s Rights and Grievances ProceduresStarting Treatment (Induction) document
I AGREE to treatment offered by Miami Valley Recovery LLC
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