San Diego County Adult Drug Court Programs

ADMISSION AGREEMENT

I, , hereby acknowledge my consent to enrollment in alcohol and drug counseling treatment services provided by a San Diego County Adult Drug Court Program. I expressly acknowledge that all the information I have furnished upon intake is true to the best of my knowledge and confirm that I am not enrolled in any other alcohol and drug abuse program at this time. I agree to submit payment for my treatment program fees, in the amount of $ 20 per week, for a minimum of 78 weeks. I understand that my treatment fees are due each week for as long as I remain in treatment.

I have been made aware that only authorized program personnel will have access to my file and that no records, statements, or data contained therein may be used to prosecute, charge, or otherwise infringe upon my Civil Rights. Thus, the confidentiality of my records has been assured to me as stipulated by Code of Federal Regulations, Title 42, Part 2.

CLIENTS ARE REQUIRED TO:

1.  Be prompt for all scheduled appointments.

2.  Attend individual and group alcohol and drug counseling as required.

3.  Agree to adhere to counseling treatment as outlined in their treatment plan

4.  Pay all fees for their treatment according program guidelines.

PROGRAM RULES AND REGULATIONS:

Violations of any of these rules shall be cause for immediate termination from the program:

1.  Any form of violence, physical abuse, or destruction of property; this includes threats of physical violence.

2.  Verbal or abusive language while receiving services at the program.

3.  Possession of drugs or alcoholic beverages on the premises. Clients are prohibited from drug dealing or drug/alcohol use on or about the premises.

4.  Persistent failure to appear at the clinic; this would include three consecutive unexcused absences within one month.

5.  Loitering in the parking lot or in the building.

6.  Theft, which includes property of the clinic or clinic staff.

7.  Threats of violence or disruptive behavior.

8.  Not adhering to: A. Program rules; B. Treatment plan; or C. any other condition agreed upon by you and your counselor.

GRIEVANCE PROCEDURE:

Each client who has a grievance with a San Diego County Adult Drug Court Program or with a particular employee of this organization or wishes to appeal their discharge has the right to a hearing by contacting:

1.  The Program Manager. If the matter is not resolved within ten (10) business days it will be referred to;

2.  The appropriate Division Manager. If the matter is still not resolved within fifteen (15) business days the matter will be referred to:

3.  The Executive or Clinical Director of Mental Health Systems or their designee. If the resolution is not reached within fifteen (15) business days the matter will be referred to;

4.  The MHS Board of Directors for final resolution within 30 business days.

I recognize that I am entitled to quality services and that I will not be discriminated against on the basis of my race, ethnic origin, nationality, sex, age, religion, or my ability to pay.

Client Signature Date

Witness Signature Date

Revised: 01/01/2009 C:\Documents and Settings\gledezma\Local Settings\Temporary Internet Files\OLK95\Admissions Agreement.doc