IDRC Client Selection of Affiliate - 48

Client Name*

First Name

Last Name

Email

I am a client of New Hope IBHC Central Region 48 Hour IDRC and have have been referred to additional assessment, education or treatment for completion of my IDRC program requirements.

This statement is to certify that a list of approved treatment providers has been shown to me and that I selected the following program

Treatment Provider Choice

Choose Your County

Choose Your Treatment Program - Atlantic

Choose Your Treatment Program - Bergen Co

Choose Your Treatment Program - Burlington Co

Choose Your Treatment Program - Camden Co

Choose Your Treatment Program - Cape May Co

Choose Your Treatment Program - Cumberland Co

Choose Your Treatment Program - Essex Co

Choose Your Treatment Program - Gloucester Co

Choose Your Treatment Program - Hudson Co

Choose Your Treatment Program - Hunterdon Co

Choose Your Treatment Program - Mercer Co

Choose Your Treatment Program - Middlesex Co

Choose Your Treatment Program - Monmouth Co

Choose Your Treatment Program - Morris Co

Choose Your Treatment Program - Ocean Co

Choose Your Treatment Program - Passaic Co

Choose Your Treatment Program - Salem Co

Choose Your Treatment Program - Somerset Co

Choose Your Treatment Program - Sussex Co

Choose Your Treatment Program - Union Co

Choose Your Treatment Program - Warren Co

If you have chosen OTHER please add here with name, address and phone number.

At no time was I pressured or coerced by IDRC personnel to choose one treatment program over another. (If a counselor or IDRC staff person recommended any of the treatment programs on the approved list, please indicate the reason for the recommendation)

CONFIDENTIALITY OF ALCOHOL AND DRUG ABUSE PATIENT RECORDS

The confidentiality of alcohol and drug patient records maintained by this program is protected by Federal law and regulations. Generally, the program may not say to a person outside this program that a patient attends the program or disclose any information identifying a patient as an alcohol or drug abuser unless:

The patient consents in writing
The disclosure is allowed by court order
The disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation

Violation of the Federal law and regulations by a program is a crime. Suspected violations may be reported to appropriate authorities in accordance with Federal regulations.

Federal law and regulations do not protect any information about a crime committed by a patient either at the program or against any person who works for the program or about any threat to commit such a crime.

Federal law and regulations do not protect any information about suspected child abuse or neglect from being reported under State law to appropriate State or local authorities.

Confidentiality Statement

CONFIDENTIALITY OF ALCOHOL AND DRUG ABUSE PATIENT RECORDS

The confidentiality of alcohol and drug patient records maintained by this program is protected by Federal law and regulations. Generally, the program may not say to a person outside this program that a patient attends the program or disclose any information identifying a patient as an alcohol or drug abuser unless:

The patient consents in writing
The disclosure is allowed by court order
The disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation

Violation of the Federal law and regulations by a program is a crime. Suspected violations may be reported to appropriate authorities in accordance with Federal regulations.

Federal law and regulations do not protect any information about a crime committed by a patient either at the program or against any person who works for the program or about any threat to commit such a crime.

Federal law and regulations do not protect any information about suspected child abuse or neglect from being reported under State law to appropriate State or local authorities.