Addiction Awareness OSCA 11-036 response - REDACTED.pdf

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ADDICTION AWARENESS, LLC CONSENT FOR RELEASE OF CONFIDENTIAL INFORMATION to BUCHANAN COUNTY DRUG COURT I, ____________________________________understand that services are being provided by ADDICTION AWARENESS, LLC through a contractual agreement with the Missouri Department of Corrections, Buchanan County Drug Court. As part of this contract it is necessary that we share information with the representatives of the Missouri Department of Corrections and Buchanan County Drug Court. I hereby authorize the ADDICTION AWARENESS LLC to communicate with, disclose and obtain from the Missouri Department of Corrections/Buchanan County Drug Court, the following information: Assessment results, treatment plan and updates, attendance, urinalysis results, progress in treatment, involvement in program activities, discharge needs, aftercare plan, and information needed for medical or psychological referral and their results, and ___________________________________________________ The purpose of and need for the disclosure is to inform the Missouri Department of Corrections/Buchanan County Drug Court about my treatment requirements and progress in treatment. I understand that this consent will remain in effect and cannot be revoked by me until: _____ _____ There has been a formal and effective termination or revocation of my release from the Buchanan County Drug Court Program under which I was referred into treatment, or _________________________________________________________ (other time when consent can be revoked and/or expires) I also understand that any disclosure made is bound by Part 2 of Title 42 of the Code of Federal Regulations governing confidentiality of Alcohol/Drug Abuse patient records and that recipients of this information may redisclose it only in connection with their official duties. I hereby release the Addiction Awareness LLC., from any liability which may arise as a result of the use of the information released to it, or from it, under this consent. __________________________________________________ __________________ Client Signature Chart # Date __________________________________________________ __________________ Staff Representative Title Date
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OSCA 11-036 Treatment Court Special
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Page 13 and 14: OSCA 11-036 Treatment Court Special
Page 39 and 40: Jeremiah W. (Jay) Nixon Governor Ge
Page 41 and 42: John Sutherland Counseling 902 Edmo
Page 43 and 44: IXlllBn \ rRIOK tVt klt'
Page 45 and 46: EXHIBIT .. PIUOS t XUBl t )(C£ Tho
Page 47 and 48: EDlI8IT .. ""01 E"7'-"f"'" ~ ___...
Page 49 and 50: • Fa mily Inlen 't ntiu n Sp«ill
Page 51 and 52: Lisa Doyle, CRADC QMHP Objective To
Page 53 and 54: I'rofn_Su........., --. "010 ......
Page 55 and 56: • • • T_hina .......... 7·10
Page 57 and 58: Evelyn Coffman Office Manager 4/198
Page 59 and 60: • Individual counseling , group c
Page 61 and 62: Rita Miller Goal: To become a subst
Page 63: State of Missouri Office of Adminis
Page 67 and 68: What do you expect/need from treatm
Page 69 and 70: Signature: Title Date: Progress Not
Page 71 and 72: 02/28/2011 ENTER SITE NAME HERE Pag
Page 81 and 82: addicted individual. Alcoholism and
Page 83 and 84: JUSTICE 9. Made direct amends to su
Page 85 and 86: chemical dependency or experiencing
Page 87 and 88: you see someone else do something n
Page 89 and 90: When you have achieved all the requ
Page 91 and 92: 6. Be well-groomed and clean for al
Page 93 and 94: Community of the results of Level-U
Page 95 and 96: ___________________________________
Page 97 and 98: Addiction Awareness, LLC DRUG COURT
Page 99 and 100: G. Behavioral Objective (Interventi
Page 105 and 106: ADDICTION AWARENESS, LLC PROGRAM SU
Page 107 and 108: ADDICTION AWARENESS LLC EVALUATION
Page 109 and 110: --------- City of Saint Joseph, Mis
Page 111: '_od •• 1___ ""It.,.. I ~ ll'::
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Addiction Awareness OSCA 11-036 response - REDACTED.pdf

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