DJJ Form MHSA012 "Youth Consent for Substance Abuse Treatment - Sample" - Florida

What Is DJJ Form MHSA012?

This is a legal form that was released by the Florida Department of Juvenile Justice - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2006;
  • The latest edition provided by the Florida Department of Juvenile Justice;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of DJJ Form MHSA012 by clicking the link below or browse more documents and templates provided by the Florida Department of Juvenile Justice.

ADVERTISEMENT
ADVERTISEMENT

Download DJJ Form MHSA012 "Youth Consent for Substance Abuse Treatment - Sample" - Florida

549 times
Rate (4.4 / 5) 38 votes
FLORIDA DEPARTMENT OF JUVENILE JUSTICE
Youth’s Name _______________________________________________ Date of Birth __________________
JJIS _______________________________________________________
SAMPLE
YOUTH CONSENT FOR SUBSTANCE ABUSE TREATMENT
I, _________________________________________ hereby consent to substance abuse
(Name of Youth)
treatment provided in the Department of Juvenile Justice (DJJ) facility or program
at
( DJJ facility/program name and address)
I understand that my substance abuse treatment will include, but not be limited to, substance abuse
assessments, drug education, individual and group counseling, relapse prevention, and life skills training.
I understand that my substance abuse treatment will be confidential, with the exception that my
substance abuse assessment results and treatment progress shall be made available to my juvenile
probation officer, the court system and DJJ personnel or agents involved in providing, coordinating or
monitoring my treatment.
I understand that I can revoke this consent at any time, and further understand that revocation of my
consent shall result in termination of my substance abuse treatment or return to court.
This consent will automatically expire the date on which my substance abuse treatment is complete.
______________________________________________
__________________________
(Signature of Youth)
(Date)
______________________________________________
__________________________
(Signature of Designated Staff Member)
(Date)
______________________________________________
__________________________
(Witness Signature)
(Date)
Rule 63N-1
MHSA 012
August 2006
FLORIDA DEPARTMENT OF JUVENILE JUSTICE
Youth’s Name _______________________________________________ Date of Birth __________________
JJIS _______________________________________________________
SAMPLE
YOUTH CONSENT FOR SUBSTANCE ABUSE TREATMENT
I, _________________________________________ hereby consent to substance abuse
(Name of Youth)
treatment provided in the Department of Juvenile Justice (DJJ) facility or program
at
( DJJ facility/program name and address)
I understand that my substance abuse treatment will include, but not be limited to, substance abuse
assessments, drug education, individual and group counseling, relapse prevention, and life skills training.
I understand that my substance abuse treatment will be confidential, with the exception that my
substance abuse assessment results and treatment progress shall be made available to my juvenile
probation officer, the court system and DJJ personnel or agents involved in providing, coordinating or
monitoring my treatment.
I understand that I can revoke this consent at any time, and further understand that revocation of my
consent shall result in termination of my substance abuse treatment or return to court.
This consent will automatically expire the date on which my substance abuse treatment is complete.
______________________________________________
__________________________
(Signature of Youth)
(Date)
______________________________________________
__________________________
(Signature of Designated Staff Member)
(Date)
______________________________________________
__________________________
(Witness Signature)
(Date)
Rule 63N-1
MHSA 012
August 2006