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    [/md-text] [md-text label="Your name" tabletwidth="4" desktopwidth="6"]

    [/md-text] [md-text label="DOB" tabletwidth="4" desktopwidth="6"]

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    [/md-text] [md-text] Information requested by: Joseph Patterson, PhD. CSAT, Crosswinds Counseling Services, 512 E Southern Ave. Ste C, Tempe. AZ. 85282

    [/md-text] [md-text]Nature of information to be disclosed:[/md-text]

    History and Physical, Drug Abuse record, Educational Report, Court/Legal records, Alcohol abuse records, Treatment Plan Consultations, Psychological Evaluation and Mental Health Records.
    [md-text label="Other" tabletwidth="6" desktopwidth="12"]


    This consent for disclosure of information whose confidentiality is protected by federal laws includes special authorization to release medical information under the drug abuse office and treatment act of 1972 (PL 92-255) and the comprehensive alcohol abuse and alcoholism prevention, treatment and rehabilitation act amendments of 1974 (PL 93-282). I certify that this request has been made freely, voluntarily and without coercion and that the information specified above is true and correct to the best of my knowledge. I authorize and consent to the disclosure by the above named facility and/or persons of information, records, documents, reports, clinical abstracts, histories and charts relating 10 my condition, care and treatment and consent to furnishing photostatic copies of same. I understand that I may revoke this consent at any time except to the extent that action has already been taken to comply with it. Without express revocation, this consent will automatically expire 90 days after the termination of treatment at CCS. If I am no longer receiving services at CCS on the date of the signature, the consent will automatically expire 90 days from the date of the signature unless I express written revocation at an earlier date.

    Re-disclosure of any medical records by those receiving the above authorized information may not be accomplished without my further written consent.


    [md-text label="Current living situation - ie living alone, roommate, with family..." tabletwidth="4" desktopwidth="12"]


    Emergency contact


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    Referring Agency

    [md-text label="Name of agency"]

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    Problem statement:
    Client assigned education/treatment due to DUI arrest.

    Goals: Client will be able to demonstrate that they have gained knowledge regarding the effects of alcohol/drugs on the body, mind and emotions. They will also demonstrate knowledge of the legal and economic realities of receiving a DUI. They will also become knowledgeable regarding treatment alternatives.

    Tasks: The client will participate and complete assignments as assigned.

    Frequency of treatment: The client will complete at least 1 lesson per week, until completion of treatment.

    Completion date: Course must be completed within 4 months or start date.

    Discharge goals/plan: Client will demonstrate knowledge by successfully completing the DUI Post Test with at least 70% accuracy.

    I have participated in the creation of my treatment plan and agree to participate fully.

    Please use your mouse our touch screen to sign below.