It is important that you understand the kinds of services you will be provided and the terms and conditions under which these services will be offered. 
I,   , am requesting treatment from the staff of   . As a condition of that treatment, I acknowledge the following items and agree to them. (Please initial each item.) 
I understand:   1. The staff believes that the outpatient treatment strategies the program uses provide a useful intervention for chemical dependence problems; however, no specific outcome can be guaranteed.  
  2. Treatment participation requires some basic ground rules. These conditions are essential for a successful treatment experience. Violation of these rules can result in treatment termination. 
I agree to the following: a. It is necessary to arrive on time for appointments. At each visit I will be prepared to take urine and breath-alcohol tests. 
b. Conditions of treatment require abstinence from all drug and alcohol use for the entire duration of the treatment program. If I am unable to make this commitment, I will discuss other treatment options with the program staff. 
c. I will discuss any drug or alcohol use with the staff and group while in treatment.  
d. Treatment consists of individual and group sessions. Individual appointments can be rescheduled, if necessary. I understand that group appointments cannot be rescheduled and attendance is extremely important. I will notify the counselor in advance if I am going to miss a group session. Telephone notification may be made for last-minute absence or lateness.
e. Treatment will be terminated if I attempt to sell drugs or encourage drug use by other clients.
f. I understand that graphic stories of drug or alcohol use will not be allowed.

g. I agree not to become involved romantically or sexually with other clients.
h. I understand that it is not advisable to be involved in any business transactions with other clients.
i. I understand that all matters discussed in group sessions and the identity of all group members are absolutely confidential. I will not share this information with nonmembers. 
j. All treatment is voluntary. If I decide to terminate treatment, I will discuss this decision with the staff.  
  3. Staff: Services are provided by psychologists, licensed marriage and family counselors, master’s-level counselors-in-training, or other certified addiction staff people. All nonlicensed counselors are supervised by a licensed counselor trained in the treatment of addictions.  
  4. Consent to Videotape/Audiotape: To help ensure the high quality of services provided by the program, therapy sessions may be audiotaped or videotaped for training purposes. The client and, if applicable, the client’s family consent to observation, audiotaping, and videotaping.  
  5. Confidentiality: All information disclosed in these sessions is strictly confidential and may not be revealed to anyone outside the program staff without the written permission of the client or the client’s family. The only exceptions are when disclosures are required or permitted by law. Those situations typically involve substantial risk of physical harm to oneself or to others or suspected abuse of children or the elderly.  
  6. Accomplishing treatment goals requires the cooperation and active participation of clients and their families. Very rarely, lack of cooperation by a client may interfere substantially with the program’s ability to render services effectively to the client or to others. Under such circumstances, the program may discontinue services to the client.

I certify that I have read, understand, and accept this Service Agreement and Consent. This agreement and consent covers the length of time I am involved in treatment activities at this facility.   

Client’s Signature:    Date: