20-3D

Treatment Program Informed Consent for Treatment

Name: ___________________________________________ Number: _________________________

As a participant in the addictions treatment program at La Palma Correctional Center I consent to

observation, evaluation, care and program services for my alcohol and/or drug related problems. I
understand that a free exchange of all clinical information will occur among program staff.

I understand that I will be assigned a primary counselor who will complete a biopsychosocial assessment
to determine my treatment issues and develop a treatment plan with me to address the identified
treatment issues. I understand that group and individual treatment interventions will be provided to
assist me in identifying and correcting the negative criminogenic and cognitive-behavioral influences
that contribute to my substance abuse and criminal behavior. I consent participate in all program
services to the best of my abilities and In accordance with the established program procedures, policies,
guidelines and rules.

I understand that discharge from the program may result upon:

 Documented repeated violation of the house/program standards (Unsuccessful Discharge);
 Documented lack of effort to reach stated goals (Unsuccessful Discharge);
 Disrespectful behavioral/attitudes toward staff (Unsuccessful Discharge);
 Signing out of or refusing to participate in the program (Unsuccessful Discharge);
 Violation of Cardinal Standards (Unsuccessful Discharge);
 Time being spent in Disciplinary Confinement (Unsuccessful Discharge);
 Medical or mental health issues that would prevent the participant from being a part of the program
(Administrative Discharge).
 Being released or transferred from the institution (Administrative Discharge); or
 Through clinical staffing determination that optimal program benefit has been obtained
(Administrative Discharge).

I understand that unsuccessful discharge may result in disciplinary action and I consent to accept the
consequences associated with this discharge status. By signing this form, I acknowledge that I have been
informed about my rights as a participant in this program, the limits of confidentiality, and the
established grievance procedure. I also indicate that I have read or been read this statement and that I
agree to participate in substance abuse program services.

________________________________________________ ________________________________
Participant Signature Date

_________________________________________________ ________________________________
Counselor Signature RudolphKolderMA Date

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