Substance Abuse Treatment Consent Form

Substance Abuse Treatment Consent Form

Client Information

Client Name:

Provider Information

Scope of Treatment

The client consents to outpatient substance use disorder evaluation and treatment services provided by the above-named provider. Treatment may include individual and/or group therapy, psychosocial interventions, counseling, case management, medication-assisted treatment when clinically indicated, toxicology testing, and coordination with other care providers as necessary.

Risks, Benefits, and Alternatives

I acknowledge that my clinician has explained the risks, anticipated benefits, and reasonable alternatives to the proposed treatment. Risks may include discomfort when discussing traumatic events, medication side effects, or changes in relationships. Benefits may include reduced substance use, improved health and functioning, and enhanced coping skills. Alternatives may include referral to other treatment modalities or higher levels of care.

I acknowledge that risks, benefits, and alternatives have been explained to me in terms I can understand.

Confidentiality and Limits

Records of treatment are confidential and will not be released without my written authorization except where permitted or required by law. Exceptions to confidentiality include: (1) situations where there is a serious risk of harm to self or others; (2) suspected abuse or neglect of a minor, dependent adult, or elder; (3) mandatory reporting obligations; (4) a valid court order; and (5) when coordination of care requires limited disclosure to other treating providers as necessary for my care. Provider may also disclose to persons responsible for payment as necessary to process claims.

I understand the confidentiality protections and the stated exceptions.

Authorization to Release Information (Optional)

I authorize the provider to disclose treatment information to the persons or entities identified below for purposes of coordination of care, billing, and continuity of services. I understand that this authorization may be revoked in writing except to the extent that action has been taken in reliance on it.

Payment and Billing

I understand that I am responsible for payment of services as set forth by the provider. If payment is to be made by insurance, I authorize the provider to submit claims on my behalf and to release necessary information to process claims. If I fail to pay amounts owed when due, I may be responsible for late fees and collection costs as permitted by applicable law.

Voluntary Consent; Right to Withdraw

I understand that participation in treatment is voluntary. I may revoke this consent at any time in writing, except to the extent that action has already been taken in reliance on this consent. Revocation will not affect disclosures already made pursuant to this consent or my obligation to pay for services rendered.

Interpreter / Special Needs

I require an interpreter or other accommodation.

Acknowledgements

By checking the boxes below I acknowledge and consent as follows:

I voluntarily consent to receive substance abuse treatment as described above.

I consent to clinically indicated medications as part of my treatment when prescribed and explained by my clinician.

I consent to urine, blood, or other toxicology testing as part of treatment protocols when clinically necessary.

Governing Law and Entire Agreement

This consent is governed by the laws of the state in which the treatment is provided. This document contains the entire agreement and understanding between the client and the provider regarding consent to the specified treatment and supersedes any prior oral statements or agreements concerning consent.

Additional Instructions / Special Conditions

Client Certification and Signature

I certify that I have read (or have had read to me) the information in this form, that my questions about the treatment and its risks and benefits have been answered to my satisfaction, and that I consent to the treatment and related activities described above. I understand that I may withdraw this consent at any time by providing written notice to the provider.

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