Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Substance Abuse Treatment Consent Form
Your information
Patient Full Name *
Date of Birth
____ / ____ / ________
Treatment Program Type
Substances of Concern
Medication-Assisted Treatment Consent
Drug Testing Policy Acknowledged
Additional details
42 CFR Part 2 Confidentiality Acknowledged
Emergency Contact Name
Name
Relationship
Phone
Emergency Contact Phone
Consent to Treatment
Your practice's consent wording goes here.
Signature
Date
Patient Signature
Date
Date of Consent
____ / ____ / ________
Substance Abuse Treatment Consent Form template from formisoft.com. formisoft.com/intake-templates/substance-abuse-treatment-consent