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Testing the publishddddd
DRUG TESTING AUTHORIZATION & CONSENT
Client Name
*
First
Last
Client Date of Birth
*
MM slash DD slash YYYY
Client is (check one):
*
Self
Child
Parent/Guardian’s name (if client <13 years of age)
Parent/Legal Guardian Name
First
Last
Parent/Legal Guardian Phone
Consent and Authorization for Drug Testing
I, the undersigned parent/legal guardian, hereby knowingly and voluntarily authorize and consent for my child to participate in the collection and testing of specimens of my child’s urine by Child and Family Agency for the purpose of drug testing.
I, the undersigned client, hereby knowingly and voluntarily authorize and consent to participate in the collection and testing of specimens of my urine by Child and Family Agency for the purpose of drug testing.
I acknowledge that drug tests may happen at random and will occur at the discretion of the clinician. I acknowledge that the drug test results will not be shared with outside agencies by Child and Family Agency.
I further acknowledge that results of the drug test will be discussed in session with family members for the purpose of treatment.
I recognize that no action will be taken against me by Child and Family Agency because of a positive drug test.
I acknowledge that I have the right to receive a copy of this authorization. I have read and understood the Consent and Authorization in its entirety, and I agree that a copy of this document is as valid as the original.
Consent
*
I agree
I decline
Today's date
*
MM slash DD slash YYYY
Parent/Legal Guardian Signature (if client <13 years of age)
Client Signature
