Residential Substance Abuse Program Consent Form
Participant Information
Full Name
Date of Birth
Address
Phone Number
Program Information
Program Name
Start Date
Expected End Date
Consent Acknowledgement
I voluntarily agree to participate in the Residential Substance Abuse Program.
I authorize the program staff to provide necessary care and support.
I understand the rules and requirements of the program.
I consent to the collection and sharing of relevant health information within legal limits for my care.
I understand my participation is confidential, unless disclosure is required by law.
Signature
Participant Signature
Date
Staff/Witness Signature
Date