Attachment 5 - Consent Form

Attachment 5

Sample Consent Form

The purpose of your participation in this data collection activity is to collect information to assess the effectiveness of treatment services received by you (and/or your children) here at _________________________. You and/or your child’s participation is

(Name of Treatment Agency)

encouraged but completely voluntary. The expected duration of this data collection activity is approximately fourteen months. You and/or your child have the right to stop participating in this data collection activity at any time without discontinuing your treatment services for yourself or your child.

The risk in participating in this data collection is seen as minimal. However, because some questions are of a sensitive nature, you or your child may feel uncomfortable. To minimize this risk, precautions have been taken to select questions that are frequently asked in Substance Abuse treatment programs. In the event you or your child become uncomfortable answering any of these questions, there will be clinically trained staff to provide any necessary support services.

If you have any questions regarding this data collection activity, please contact

_______________________________________________________________________

Name/Title/Address/Phone Number

By signing below, I am voluntarily agreeing to have myself and or my child participate in this data collection activity.

_____________________________________________________________________________________

Name (Print Name) Signature of Child Date

_____________________________________________________________________________________

Name (Print Name) Signature of Parent, Guardian or Authorized Rep. when required Date