Alcohol Use Disorder Program Consent Form

Please read the following information carefully. By signing this form, you acknowledge and consent to participate in the Alcohol Use Disorder Program.

Program Overview

Your Rights and Confidentiality

Your participation is voluntary and you may withdraw at any time.
Your personal health information will remain confidential in accordance with all applicable laws and regulations.
With your written permission, certain information may be shared with other healthcare professionals involved in your care.

Potential Risks and Benefits

Participation may involve emotional or psychological discomfort.
Support and professional guidance will be provided throughout your participation.

Consent Statements

I have read and understood the information provided above. I have had the opportunity to ask questions, and all my questions have been answered. I voluntarily agree to participate in the Alcohol Use Disorder Program.

Participant's Name

Date

Participant's Signature

Date

Witness Name

Witness Signature

Date