Name: Date of Birth:
Center for Family Development Recovery Program utilizes urine testing in order to objectively determine whether recent drug use has occurred. Urinalysis (UA) can serve as a motivator to assist individuals in becoming drug free.
Center for Family Development requires a UA at the time of assessment, and thereafter individuals will be tested during the course of services. UA results will be utilized to further develop service recommendations. If an individual refuses to do a UA or is unable to produce the sample, it will be assumed the sample would have been positive. The integrity of UAs is an essential element of the Recovery Program. As such, UAs are monitored closely and observed as needed.
I understand that if I receive public funding or am in the DUII program, CFD must report the number of positive UAs I produce as required by the State of Oregon for the Measures and Outcomes Tracking System (MOTS). I acknowledge that dilute UAs are recorded in MOTS as positive.
UAs will be sent to the lab for analysis.
By signing below, I acknowledge that:
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.
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Your legal name
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If you have questions about the contents of this document, you can email the document owner.
Document Name: UA Authorization
Agree & Sign