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Family Training Registration

Permission to call/text/leave voicemail
Mailing Address:
  • {name}
Home Address (if different from mailing):
  • {name}
Race
Ethnicity
Relationship status:
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.

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