WP E-Signature by Approve Me - Sign Documents Using WordPress -

Recovery Program Expectations

1258 High Street, Eugene, OR 97401

Phone 541-342-8437 | Fax 541-242-2999

Recovery Program Expectations

While involved in services in the Recovery Program, you are expected to:

Help with service planning and be certain you understand all service goals and specific activities, including assessment and evaluation procedures, group and individual sessions and educational components.
Set and maintain personal goals around the use of alcohol and other non-prescribed mood-altering substances and address issues caused by use.
Follow group guidelines, sent with group email invite.
Provide urine samples when requested by treatment providers.
Abstain from tobacco use in any form (including e-cigarettes) on program facilities or groups, including virtual group rooms. If you wish to smoke, you must wait until session breaks and leave facility property. Tobacco use on facility property is not permitted.
Refrain from carrying weapons while attending appointments on program facilities or grounds. Guns, knives, and weapons of any kind are banned on facility property.
Pay any service fees assessed, including insurance co-pays, at the time of appointment.
Notify the agency of any intended absences from services at least 24 hours prior to the scheduled appointment. See no show policy.

Non-compliance with any of the above expectations can result in denial of services and may be grounds for termination from the Recovery Program. If you have any questions about these expectations, please ask your primary therapist for clarification.

This document is being signed by: ClientPersonal Representative, see below

If you are signing as the Personal Representative, please complete the following section; otherwise, proceed to signing the form.

Full legal name of Personal Representative:

Relationship to client:

Definition of Personal Representative:
For Adults: A person with legal authority to make healthcare decisions on behalf of the adult. Supporting documentation required.
For Youth: A parent, guardian, or other person acting in the place of a parent with legal authority to make healthcare decisions on behalf of the minor child. Supporting documentation may be required.

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

Draw Signature
Type In Signature

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

Adopt & Sign

Timestamp

Audit

May 16, 2024 2:16 pm PDT

Recovery Program Expectations Uploaded by Do Not Reply - donotreply@c-f-d.org IP 192.111.94.5

May 16, 2024 2:40 pm PDT

CFD Main - main@c-f-d.org added by Do Not Reply - donotreply@c-f-d.org as a CC'd Recipient Ip: 192.111.94.7