Form DOC14-186 "Substance Use Disorder Behavioral Contract" - Washington

What Is Form DOC14-186?

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

Form Details:

  • Released on August 14, 2019;
  • The latest edition provided by the Washington State Department of Corrections;
  • 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 Form DOC14-186 by clicking the link below or browse more documents and templates provided by the Washington State Department of Corrections.

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Download Form DOC14-186 "Substance Use Disorder Behavioral Contract" - Washington

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SUBSTANCE USE DISORDER
BEHAVIORAL CONTRACT
Program facility:
Treatment modality:
Name:
DOC number:
Due to my
behavior and/or
lack of progress in treatment. I have been given this final
opportunity to meet program expectations. I understand that the following behavior/lack of progress
has impeded my progress toward treatment goals in substance use disorder treatment and prevented
me from meeting program expectation up to this point:
I agree to comply with the following conditions, including but not limited to those that have been
outlined in DOC 14-039 Substance Use Disorder Treatment Participation Requirements signed
before admission to treatment. I will:
Remain free of alcohol and other drug use and/or possession of said substances
Submit to urine analysis (UA) or other drug testing, as required
Refrain from any disruptive behavior, gang activity, threats, or violence
Refrain from use of abusive language or arguments
Respect and protect the privacy, rights, and confidentiality of others in group
Attend all scheduled groups and individual appointments
Complete all Individual Service Plans and assignments by the target date
Bring all required materials to group
Participate in all group activities and discussions
By signing, I acknowledge that failure to comply with the conditions of this contract or other program
expectations as outlined in DOC 14-039 Substance Use Disorder Treatment Participation
Requirements may result in termination from substance use disorder treatment.
Signature
Date
Substance Use Disorder Professional
Signature
Date
The records contained herein are protected by Federal Confidentiality Regulations 42 CFR Part 2. The Federal rules prohibit further
disclosure of this information to parties outside of the Department of Corrections unless such disclosure is expressly permitted by the
written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. Upon completion, the data classification
category may change.
Distribution: ORIGINAL - Clinical File
COPY - Patient, Case Manager
DOC 14-186 (Rev. 08/14/19)
Page 1 of 1
Data classification category 1
SUBSTANCE USE DISORDER
BEHAVIORAL CONTRACT
Program facility:
Treatment modality:
Name:
DOC number:
Due to my
behavior and/or
lack of progress in treatment. I have been given this final
opportunity to meet program expectations. I understand that the following behavior/lack of progress
has impeded my progress toward treatment goals in substance use disorder treatment and prevented
me from meeting program expectation up to this point:
I agree to comply with the following conditions, including but not limited to those that have been
outlined in DOC 14-039 Substance Use Disorder Treatment Participation Requirements signed
before admission to treatment. I will:
Remain free of alcohol and other drug use and/or possession of said substances
Submit to urine analysis (UA) or other drug testing, as required
Refrain from any disruptive behavior, gang activity, threats, or violence
Refrain from use of abusive language or arguments
Respect and protect the privacy, rights, and confidentiality of others in group
Attend all scheduled groups and individual appointments
Complete all Individual Service Plans and assignments by the target date
Bring all required materials to group
Participate in all group activities and discussions
By signing, I acknowledge that failure to comply with the conditions of this contract or other program
expectations as outlined in DOC 14-039 Substance Use Disorder Treatment Participation
Requirements may result in termination from substance use disorder treatment.
Signature
Date
Substance Use Disorder Professional
Signature
Date
The records contained herein are protected by Federal Confidentiality Regulations 42 CFR Part 2. The Federal rules prohibit further
disclosure of this information to parties outside of the Department of Corrections unless such disclosure is expressly permitted by the
written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. Upon completion, the data classification
category may change.
Distribution: ORIGINAL - Clinical File
COPY - Patient, Case Manager
DOC 14-186 (Rev. 08/14/19)
Page 1 of 1
Data classification category 1