CONSENT & AUTHORIZATION FOR TREATMENT & CONDITIONS OF ADMISSION

1. Consent: I voluntarily consent to this admission to Treatment Solutions and a network facility.
2. Emergency Treatment and/or Hospital Transfer: I understand while at one of the network facilities, the need for detoxification, emergency treatment and/or transfer to a hospital may become necessary and appropriate. Should the need for such treatment and/or transfer be deemed necessary and appropriate by the clinical team at the facility, I consent to such emergency treatment and/or transfer to a hospital. I understand that this may not be covered by insurance.
3. Conditions of Treatment: I acknowledge and understand that the practice of substance abuse treatment is not an exact science and that there are no promises or guarantees have been made to me regarding the final outcome of my treatment by Treatment Solutions.
4. Release of Information: Treatment Solutions and the network facility may disclose all or any part of my record to any
   person or corporation which is or may be liable under a contract in order to provide care. I will be asked to sign an authorization
   to release information as soon as I am admitted at the network facility. I have a right to refuse signing a release.
5. Travel Arrangements: I will receive a confirmation code via phone for my flight. I will be picked up at the baggage claim at the airport by a facility’s staff member who will have a sign with my name written on it.
6. Scope of Practice: Treatment Solutions will provide the following service for me: insurance verification, explanation of VOB, Pre-admission assessment, Placement based on clinical picture and insurance benefits.
7. Grievance: In case I have a formal complaint against Treatment Solutions, I have a right to fill out a grievance.
   I can find information regarding the grievance procedure in Treatment Solutions webpage.
8. Client rights: I can access the client rights on the Treatment Solutions webpage.
9. Client obligations: I promise to fulfill financial obligations I have agreed to.
10. Authorization For Treatment: I know that I have voluntarily enrolled in Treatment Solutions and do herby voluntarily consent to such care-encompassing procedures and treatment by a Treatment Solutions facility that it’s Director, employees, staff physician and designees deem necessary in their judgment.

I herby certify that I am capable of mentally and physically sustaining my life.

I certify to understand and agree to the above. I am the Client, or I am duly authorized by and on behalf of the Client to execute the above and accept its terms personally and upon the Client’s behalf. I can find a copy of this document in Treatment Solutions webpage.