Family Training Registration
Permission to call/text/leave voicemail *
- Yes
- No
Mailing Address: *
- {name}
Home Address (if different from mailing):
- {name}
Race
- American Indian or Alaska Native
- Asian
- Black or African American
- Native Hawaiian or Other Pacific Islander
- White
Ethnicity
- American Indian or Alaskan Native
- Asian / Pacific Islander
- Black or African American
- Hispanic
- White/Caucasian
- Multiple ethnicity
Relationship status:
- Single
- Partner
- Spouse
- Separated
- Other
Number of Children and Ages
- {name}
Have you experienced threats, violence, or abuse related to this current situation?
Do you need resources for the following?
- DV Support Group
- Legal Advocacy
- Children's Services
- Housing Advocacy
- Mental/Behavioral Support
- Chemical Dependency Support
- Other
Authorization to Record *
I authorize staff to audio record my counseling sessions for the purpose of Community Reinforcement and Family Training (CRAFT).
I understand that these recordings may be listened to by my counselor’s supervisor and Robert J. Meyers and Associates, who have agreed to maintain strict confidentiality of this information in accordance with HIPAA and the federal rules regarding confidentiality of substance abuse treatment information located at 42 C.F.R. Part 2.
I understand that I may revoke this consent and release, in writing or verbally, at any time except to the extent that action has been taken in reliance on it.
I understand that participation is entirely voluntary. I also understand that my treatment, payment, enrollment, or eligibility for benefits is not contingent on whether or not I sign this consent and release. It has also been explained to me that if I refuse to consent, that the only consequence of refusal will be that no audio recordings will be made. I will not receive any compensation for my agreeing to audio recording of my counseling sessions.
- Yes
- No
Do not submit passwords through Airtable forms. Report malicious form