Substance Abuse Assessments Registration group or individual "*" indicates required fields Δ I will take my class in...*In personZoomEmail Address* Name* First Last Address* Street Address City State / Province / Region ZIP / Postal Code Phone*Date* Work PlaceDrivers License/State IDMarital Status*SingleMarriedDivorcedWidowedLiving With SomeoneReferred ByAttorneyCourt OrderProbationParoleSelf RefferedPre-TrialOtherAny Health or Mental Issues we should be concerned about?*Consent Form for the Release of Confidential Information (in compliance with 41 CFR Part 2)I,*Authorize Martinez & Associates Counseling Services, to disclose:*AttorneyCourtProbationFamily MemberNone(Name of persons or organizations to which disclosure is to be made)Family Member Name*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:Date*Print Name*Signature of Participant*Your NameYour NameYour NameYour NameParticipation Agreement ContractMartinez 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:1. I agree to pay fees as directed by Martinez & Associates Counseling Services court order, by a community supervision officer of the court or as self referred to cover the cost of my participation in the program. I further understand that I may be required to pay additional fees associated with court ordered referrals. I further understand that unless I have completely paid all my program fees, I will not be allowed to receive a certificate of completion. (Payment of services should be paid before services are rendered.)* I agree2. I agree to attend services as required by the schedule given by Martinez & Associates Counseling Services. As for the counseling sessions (Anger Management, Anger Resolution Therapy, Stop The Violence Program, Domestic Violence Program, Cognitive Life Skills and Parenting Sessions) participants should attend 1 session a week. If there are 3 consecutive absences, sessions will start from the beginning.* I agree3. I agree that I will not violate the laws of this state,or any other state of the United States, or any other subdivision of these jurisdictions during this period of attending services.* I agree4. I will participate in such cognitive skill building, education, counseling, and/or course programs as may be advised and that I will facilitate crime-free behavior and a productive demeanor. I will abide by the independent program rules.* I agree5. In consideration of the opportunity to participate in the program, the undersigned participant agrees to release, waive, discharge and not to sue Martinez & Associates Counseling Services, its employees. Including, but nor limited to, Webb County, and Martinez & Associates Counseling Services staff and volunteers, from all claims, demands, or causes of action of any kind whatsoever arising out of participant's participation in the program. This does not create a warranty, either expressed or implied, other than what is stated in the Martinez & Associates Counseling Services of this agreement.* I agreeThis 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.Date*Participant Signature*Your NameYour NameYour NameYour NamePlease upload your ID*Max. file size: 4 MB. "Services offered via zoom, phone call, in person, and facetime."
