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Consent

Substance Abuse Treatment Consent Form

3 pages•12 fields•HIPAA-ready
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Substance Abuse Treatment Consent Form

Page 1 of 3

Patient Full Name
Jane Martinez
Date of Birth
03/15/1985
Treatment Program Type
Select an option...
Substances of Concern
Medication-Assisted Treatment Consent
Strongly agree
Agree
Neutral
Disagree
Drug Testing Policy Acknowledged
42 CFR Part 2 Confidentiality Acknowledged
Emergency Contact Name
Contact person
Emergency Contact Phone
(555) 867-5309
Consent to Treatment
I agree to the terms above
Sign here
Patient Signature
Sign here
Date of Consent
03/15/1985
Submit
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The Substance Abuse Treatment Consent Form is specifically designed for addiction treatment facilities, detoxification centers, and outpatient substance use disorder programs. It addresses the heightened confidentiality protections afforded to substance abuse treatment records under 42 CFR Part 2, which imposes stricter requirements than standard HIPAA regulations.

This template covers treatment modalities including individual and group counseling, medication-assisted treatment (MAT), detoxification protocols, and relapse prevention planning. It includes detailed explanations of federal confidentiality protections, the circumstances under which records may be disclosed, and patient rights regarding their treatment information. The form also addresses drug testing policies and the consequences of treatment non-compliance.

Designed for use by inpatient and outpatient rehabilitation facilities, methadone clinics, community health centers with addiction services, and hospital-based substance abuse programs, this form helps providers comply with both federal substance abuse confidentiality regulations and state informed consent requirements.

What's included

  • Patient identification and demographics
  • Treatment program type and modality selection
  • Substance use history and substances of concern
  • Federal confidentiality protections disclosure (42 CFR Part 2)
  • Drug testing and compliance policy acknowledgment
  • Emergency contact and signature fields
  • Consent agreement with e-signature

Who uses this template

  • Enrolling patients in inpatient or outpatient addiction treatment programs
  • Documenting consent for medication-assisted treatment with buprenorphine or methadone
  • Ensuring compliance with 42 CFR Part 2 federal confidentiality regulations
  • Recording patient acknowledgment of drug testing and program policies

All form fields

12 fields across 3 pages. Customize any field after signing up.

Patient Full NameText
Date of BirthDate
Treatment Program TypeDropdown
Substances of ConcernCheckbox
Medication-Assisted Treatment ConsentMultiple Choice
Drug Testing Policy AcknowledgedCheckbox
42 CFR Part 2 Confidentiality AcknowledgedCheckbox
Emergency Contact NameEmergency Contact
Emergency Contact PhonePhone
Consent to TreatmentConsent Agreement
Patient SignatureE-Signature
Date of ConsentDate
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