Substance Abuse Assessments

Registration

group or individual

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Name*
Address*
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Consent Form for the Release of Confidential Information (in compliance with 41 CFR Part 2)

Authorize Martinez Associates & Counseling Services, to disclose:*
(Name of persons or organizations to which disclosure is to be made)
The following information:
My attendance, compliance, educational groups and in substance abuse treatment
(NATURE OF THE INFORMATION, AS LIMITED AS POSSIBLE)
The purpose of the disclosure authorized herein is to: Assist to Martinez Associates & Counseling Services to determine my eligibility for benefits and/or to evaluate my readiness/ability to participate in a training program.
(PURPOSE OF DISCLOSURE, AS SPECIFIC AS POSSIBLE)
I understand that my records are protected under the Federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR Part 2, and cannot be disclosed without my written consent unless otherwise provided for in the regulations. 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:

Participation Agreement Contract

Martinez Associates & Counseling Services is committed to encourage participants to embrace a lifestyle without the use of alcohol or drugs; to seek out life of responsibility, sobriety, commitment and choices by the guide of the higher power. The program is designed to provide an early opportunity for Cognitive Behavioral transformation through compliances, educational instruction and referrals.
If you agree to participate in the program, and comply with all request, please sign the following agreement:
This agreement shall be effective from this day, and will expire upon my successful completion of all Martinez Associates & Counseling Services requirements or until I am otherwise discharged from the program.
Max. file size: 4 MB.

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