Form – solutionscenter

CONSENT FOR THE RELEASE OF CONFIDENTIAL INFORMATION

I authorize the

(Full Legal Name of Individual/Consumer/Patient/ Applicant/Client)

Solution Center’s counselors, administrators, independent contractors and employees to release and disclose any and all information, documentation and supplemental information/documentation regarding my evaluation, assessments/test results and scores, attendance/progress, discharge summary, classes and/or treatment that make up my complete medical record to:

Probation Officer

Probation Department

Fax#

Mother

Father

Spouse

Other

Fax#

The purpose of this release and disclosure is: (check all that apply)

Probation/Court

Other

I understand that unless otherwise limited by state or federal regulation, and except to the extent that action has been taken based upon it, I may revoke this authorization at any time as shown in the space below.

Signature

Date

*Consent For the Release of Confidential Information expires one year from today’s date

Adult In take Form

Name

DOB

Address

Apt

City

State

Zip

Cell Phone

Home Phone

Employer/School

Reason for contacting the Solutions Center:

• Drug and Alcohol Evaluation

• Anger Management Evaluation

• Drug and Alcohol Evaluation

• Mental Health Evaluation

• SAP Evaluation

• Counseling for:

Current and all past Legal Charges:

Next court date:

Probation Officer name and contact information:

ASSURANCE AND RELEASE

I hereby attest that all the information given herein is true and complete to the best of my knowledge and belief. I will hold the Solutions Center owners, counselors, facilitators, and staff free from any civil liability for damages or complaints by reason of any action that is within the scope and arising out of the performance of their duties which they, or any of them, may take in connection with counseling, classes, assessments or evaluations.

NOTICE: Some or all of the professionals performing services at the Solutions Center are independent contractors and are not Solutions Center agents or employees. Independent contractors are responsible for their own actions and the Solutions Center shall not be liable for the acts or omissions of any such independent contractors.

Signature

Date

Printed name

Witness

Date

ACKNOWLEDGEMENT OF REFUND POLICY

Please initial next to each statement indicating that you have read, fully understand, and are in agreement with the Solutions Center Refund Policy.

The Solutions Center does not provide refunds or exchanges under any circumstances.
All sales and monetary transactions are final.

Any money given to the Solutions Center via cash or through a debit or credit card transaction online or over the phone will not be returned or refunded to me or any of my representatives or affiliates.

Any payment dispute placed by me or an affiliate who made payment on my behalf, to the Solutions Center will void any and all confidentiality rights and any and all relevant information can and will be released to the financial institution (bank, credit card company, etc.) and/or any other involved parties to resolve the dispute.

Money that I or one of my representatives/affiliates gives to the Solutions Center for one particular service or good cannot be used for a different service or good.

If I pay or someone else pays the Solutions Center on my behalf for a service(s) in advance, I have thirty (30) days from the date of payment to utilize the service before forfeiting and losing my/their money. Any attempts to utilize service(s) after 30 days will be denied without paying in full at that point. If I make an appointment and don’t keep or reschedule that appt. I have thirty (30) days to re-schedule before I forfeit and loose the money I pre-paid.

I have read and fully understand the

Client or Legal Guardian’s Name

Solutions Center Refund Policy.

Client or Legal Guardian’s Signature

Date

Witness Signature

Date

How May We Contact You?

May We Leave Messages:

(Please check “Y” for yes or “N” for no)

Regarding an appointment

On your answering machine?

On your voice mail?

With a family member or friend?

Regarding an appointment

On your answering machine?

On your voice mail?

With a family member or friend?

Regarding an appointment

On your answering machine?

On your voice mail?

With a family member or friend?

Phone: (501) 288 - 6676

Email: arsolutionscenter@gmail.com

CONSENT FOR THE RELEASE OF CONFIDENTIAL INFORMATION

Adult In take Form

ACKNOWLEDGEMENT OF REFUND POLICY

How May We Contact You?