SA IOP/SUCM Signature Page

SA IOP/SUCM Signature Page
I attest to verbal consent for all admission documentation at the time of my assessment. My signature now further attest that I have received, understood, and in agreement with the following forms reviewed with me and explained further within the IOP Client Handbook.
Admission Documents:
RCCCS/RCRS Freedom of Choice to Request Services - 1st Intake Doc

RCCCS/RCRS Notification of Human Rights - 2nd Intake Doc

RCCCS/RCRS Orientation Checklist - 3rd Intake Doc

RCCCS/RCRS Release of Liability Waiver - 4th Intake Doc
Releases of Information:
Release of Information – Primary Care Physician (PCP) and/or other Medical Providers

Release of Information – Psychiatrist Release of Information – Therapist

Release of Information - Other Providers (i.e., Treatment Centers)

Release of Information - Supportive Housing

Release of Information - MAT Practitioner

Release of Information - Emergency Contact

Release of Information – Probation & Parole
Treatment:
SUS Individualized Service Plan (ISP) Initial/Comprehensive/90 Day

Quarterly Reports

Relapse Prevention Plan

Overdose Safety Plan

Safety Plan
Individual Signature *

Clear
SA IOP Drug Testing Informed Consent Form
At River City Comprehensive Counseling, we endorse the American Society of Addiction Medicine belief that addiction is a chronic relapsing disease of brain reward, motivation, and memory that is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors. The inherent psychological defenses and dysfunctional thinking patterns caused by substance use disorders often influence individuals to misreport information.

The River City Substance Abuse Intensive Outpatient Treatment Program includes random drug testing as a foundational component to maintain the integrity of our clinical therapeutic environment. At River City, our primary screening method is CLIA-waived urine analysis Point-of-Care tests utilized to monitor the accuracy of participant’s self-reports. At River City, we believe that change is possible but first requires self-honesty, acceptance, and engagement in the therapeutic treatment process. These test results are confidential and protected by federal statute 42 CFR Part II. To confirm accuracy of results, River City is contracted with Scientia Diagnostics (SDX) and/or Lab Corp. to send specimens for definitive confirmation testing.
I, *
, understand that drug screening is a foundational component
of the Substance Abuse Intensive Outpatient Treatment Program and that screens are given on a random basis approximately 1-2 times per month with potential increase/decrease in frequency based upon consistent positive/negative results. I understand the intent of River City in maintaining accountability to my self-reports of substance use and the importance of providing honest and accurate reports. *

I intend to comply and participate in all Drug Testing associated with the SA IOP. I DO NOT intend to comply and participate in all Drug Testing associated with the SA IOP but understand that this document will be presented again within 14 days and I could be potentially discharged with a referral to a more suitable treatment service if I am unwilling to reconsider. My signature below indicates my understanding and informed consent to all the information above.
Individual Signature

Clear
Should be Empty:

SA IOP/SUCM Signature Page

Admission Documents:

Releases of Information:

Treatment:

SA IOP Drug Testing Informed Consent Form