Digital Pre-Admission Form

We’re excited to welcome new patients to begin the induction process by completing the Intake Form below. Submitting this form will streamline your first appointment, saving you valuable time—up to an hour—and providing faster access to medication and relief.

Please note that the form MUST be completed by the patient only and filled out in a single session. Rest assured, your information will remain secure throughout the process. To complete the form, you should have the following (if you do not, we will work with you and address these during your appointment):

• Picture of ID
• Picture of Insurance Card

If you have any questions, please contact telehealth@cmglp.com.

Thank you for choosing New Season as your partner in your recovery journey! You have taken the courageous first step in seeking treatment for opioid addiction and we look forward to walking alongside you every step of the way.

Do you have insurance?
Yes No - Please indicate whether you have insurance.

This Notice of Privacy Practices (the “Notice”) describes:

• HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED;
• YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION; AND
• HOW TO FILE A COMPLAINT CONCERNING A VIOLATION OF THE PRIVACY OR SECURITY OF YOUR HEALTH INFORMATION, OR OF YOUR RIGHTS CONCERNING YOUR INFORMATION.

YOU HAVE A RIGHT TO A COPY OF THIS NOTICE (IN PAPER OR ELECTRONIC FORM) AND TO DISCUSS IT WITH OUR PRIVACY OFFICER AT 407.351.7080 EXT. 11140 OR bill.sutton@cmglp.com IF YOU HAVE ANY QUESTIONS.

You have the right to:

• Get a copy of your paper or electronic medical record
• Make corrections to your paper or electronic medical record
• Request confidential communication about your treatment
• Ask us to place restrictions on the information we share, including disclosures made with your prior consent for purposes of treatment, payment or healthcare operations
• Revoke any previous written consent that you gave for the use or disclosure of your health information
• Get a list of those with whom we’ve shared your health information for the past three years
• Get a copy of this Notice
• Discuss this Notice with a designated contact person from our organization
• Not receive any fundraising communications
• File a complaint if you believe your privacy rights have been violated

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities.

Get an electronic or paper copy of your medical record

• You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
• We will provide a copy or a summary of your health information, usually within thirty (30) days of your request. We may charge a reasonable, cost-based fee to produce these records which may be determined by applicable state laws or regulations.

Ask us to correct your medical record

• You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
• We may say “no” to your request, but we’ll explain to you why in writing within sixty (60) days of your request.

Request confidential communications

• You can ask us to contact you in a specific way (for example, by calling your home or cell phone) or to send mail to a different address.
• We will agree to all reasonable requests.

Ask us to limit what we use or share

• You have the right to ask us to restrict the use or disclosure of your health information for treatment, payment, or our operations. We are not required to agree to your request, particularly if your request will adversely impact your treatment or if your health information is needed to provide emergency medical treatment to you.
• If you give us your written consent to disclosure your health information to another Part 2 addiction treatment program (as that term is defined in 42 C.F.R. § 2.11, a covered entity health care provider, or a business associate for treatment, payment or health care operations may be further disclosed by that Part 2 program, covered entity health care provider or business associate without your written consent provided that such disclosures are permitted by the Health Insurance Portability and Accountability Act (“HIPAA”) and HIPAA regulations.
• If you paid in full for a service or health care item out of your own pocket, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will agree to this restriction unless a law or contract provision with your health insurer requires us to share that information.

You have a right to list of those to whom we’ve disclosed your health information

• You have a right to ask for a list of all disclosures (an “accounting) of your health information made with your consent in the three (3) years prior to the date of your request.
• You also have a right to ask for a list of all disclosures of your health information made by an intermediary (i.e., a covered entity health care provider or the covered entity’s business associate) who received your information with your consent in the three (3) years prior to the date of your request.

Get a copy of this Notice
You can ask for a paper copy of this Notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly. A copy of this Notice is also available on our website at www.newseason.com.

File a complaint if you feel your privacy rights were violated

• You can complain if you feel we have violated your rights by contacting our Privacy Officer at 407.351.7080 ext. 11140 or bill.sutton@cmglp.com.
• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
• We will not retaliate against you for filing a complaint.

You have some choices in the way that we use and share information as we:

• Communicate with your other healthcare providers
• Communicate with your health insurance plan
• Speak with your family and friends about your treatment
• Create awareness in your community about opioid use disorder

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will attempt to follow your instructions.

In these cases, you have both the right and choice to tell us to:

• Share information with your other health care providers, their business associates or your health insurer
• Share information with your family, close friends, or others who are supporting you in your treatment
• Share information in a disaster relief situation

If you're unable to tell us your preference if, for example, you are unconscious or require emergency medical care, we may choose to share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:

• Participating in community awareness activities
• Partnering with non-profit entities to provide additional services to our patients
• Disclosing the counseling notes created during the course of your treatment

In the case of fundraising:

• We may contact you as part of our fundraising efforts, but only if you give the right to do so. Before we contact you, you will be given the opportunity to tell us not to contact you for anything that concerns our fundraising efforts.

How do we typically use or share your health information?
We typically use or share your health information in the following ways.

Providing treatment to you (“Treatment”)
We can use your health information and share it with other medical and behavioral health professionals who are treating you.

Example: The clinic’s medical doctor who is treating you speaks with your counselor about your overall health condition.

Running our organization (“Operations”)
We can use and share your health information to run our organizations, improve your care, and contact you when necessary.

Example: We use your health information to manage your treatment and services and keep your medical records up to date.

Billing for the services provided to you (“Payment”)
We can use and share your health information to bill and receive payment from health insurers, including Medicare, Medicaid and commercial health insurance plans.

Example: We give information about you to your health insurance plan so it will pay for the services we provide to you.

PLEASE NOTE THAT FOR TREATMENT, OPERATIONS AND PAYMENT PURPOSES ONLY, YOU MAY PROVIDE A SINGLE, ONE-TIME CONSENT FOR ALL USES AND DISCLOSURES OF YOUR INFORMATION.

How else can we use or share your health information? Under federal law, there are a few limited instances where we can share your health information without your consent. These instances are:

• Disclosures to emergency medical personnel in response to a bona fide medical emergency
• Bona fide scientific research provided that the research entity meets all of the applicable requirements of the HIPAA regulations
• Management audits, financial audits and program evaluations by entities who are legally authorized to perform such audits and evaluations
• To report suspected incidents of child abuse and neglect
• To report crimes occurring on a clinic’s premises or against a clinic employee

Comply with the law
We will share information about you if state or federal laws require it, including with the U.S. Department of Health and Human Services if that agency is assessing our compliance with federal privacy laws.

Responding to lawsuits and legal actions
Your health information or testimony about your health information will not be used or disclosed in any civil, criminal, administrative or legislative proceeding involving you without your written consent or a court order. Your health information shall only be used or disclosed based on a court order after notice and an opportunity to be heard is provided to you and us as required by 42 U.S. Code § 290dd-2 and 42 C.F.R. Part 2. Any court order authorizing the use of disclosure of your health information must be accompanied by a subpoena or other similar legal document requiring disclosure before your health information is used or disclosed.

PLEASE NOTE THAT FOR ANY OTHER USES AND DISCLOSURES OF YOUR INFORMATION THAT ARE NOT SPECIFICALLY MENTIONED OR OTHERWISE DESCRIBED IN THIS NOTICE, WE WILL NOT MAKE SUCH USES OR DISCLOSURES WITHOUT YOUR EXPRESS WRITTEN CONSENT.

• We are required by law to maintain the privacy and security of your protected health information, and to provide you with a notice of our legal duties and privacy practices with respect to your health information.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your health information.
• We are required to abide by the terms of this Notice and provide you a copy of it upon request.
• We will not use or share your information other than as described in this Notice unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

Changes to the Terms of this Notice
We reserve the right to make changes to the terms of this Notice, and the changes will apply to all health information we have about you. A new notice will be available to you upon request, at our centers, and on our web site at www.newseason.com.

Acknowledgment:
By signing below, I acknowledge that I have received this Notice of Privacy Practices and have been offered an opportunity to request restrictions on certain uses and disclosures of my protected health information.

The confidentiality of alcohol and drug abuse patient records maintained by this program is protected by federal law and regulations. Generally, the program may not disclose any information about any patient, except under the following exceptions:

1. Internal program communications
2. Communications that do not disclose the identity of the patient
3. Proper written consent provided by the patient
4. Communications during medical emergencies
5. Court-ordered disclosures
6. Communication with law enforcement officials regarding crimes committed by patients on clinic premises or against clinic employees
7. Communications in conjunction with research, audit, or evaluation
8. Reporting of suspected child abuse and neglect
9. Qualified service organization agreement (QSOA)

Violations of the federal law and regulations by a program are a crime. Suspected violations may be reported either at the program or against any person who works for the program or about any threat to commit such a crime.

The center is required by federal law to provide you with a copy of the policy outlined above. A copy of this policy is contained in the Patient Handbook.

State and federal law protect your records and the fact that you are enrolled in our program. You will receive further information in this regard elsewhere in the intake process. The purpose of this notice is to inform you of our expectations for the confidentiality YOU extend to OTHER PATIENTS. We expect you to respect the confidentiality of other patients you know or meet while you are in treatment at our center. In other words, what you see here and what you hear here, must stay here. Do not violate another person’s confidentiality by carrying tales out of the center.

I have read and understand Federal Confidentiality Rule and Regulations as they apply to my treatment and the treatment of all other patients at New Season (For details, see 42 CFR, Part 2).

Patient Name:

Date: 11/19/2025

As a client receiving addiction services through Telehealth methods with , I understand there are both benefits and limitations to this service; I also understand the following:

1. This service is provided using secure technology (including but not limited to video, phone, text, and email) and may not involve direct, in person communication. I will need uninhibited access to and familiarity with the appropriate technology to participate in the service provided.
2. These services rely on secure technology, which allows for greater convenience in service delivery; although we take every precaution to ensure continued confidentiality of your personal information, some risks still apply. The inherent risks in transmitting information over the internet include, but are not limited to, breaches of confidentiality, theft of personal information, and disruption of service due to technical difficulties.
3. My Telehealth provider and I will regularly reassess the appropriateness of continuing to deliver services to me through the use of technology.
4. Exchange of documentation may not be direct and any paperwork exchanged will likely be exchanged through secure electronic means or through postal delivery.
5. Upon initiation of remote Telehealth services, my emergency contact person will be confirmed by my Telehealth provider and I will have the opportunity to designate an alternate individual who may be contacted in the case that an emergency arises outside of the clinic, during the course of my Telehealth care.
6. If a need for an in person counseling session arises, it is my responsibility to contact this office for an in person counseling appointment. I understand that an opening may not be immediately available and that I will need to provide transportation to and from the appointment.
7. I understand that my participation in Telecounseling and/or Telemedicine services is voluntary.
8. There may be a need to communicate by other methods during times of service disruption; if there is a disruption of services for either the Telehealth provider or the patient, the Telehealth provider or member of the Telehealth team will attempt to contact within 24 hours to reschedule.
9. My Telehealth provider or designee will respond to email communications and routine messages within 48 business hours of receipt of the email.
10. It is my sole responsibility to ensure I have a stationary private setting for my Telehealth service and maintain my privacy during remote appointments..
11. The laws and professional standards that apply to in-person counseling and medical services also apply to Telehealth services.
12. This document does not replace other agreements, contracts, or documentation of informed consent.

Patient Name:

Date: 11/19/2025

Please answer each of the following questions.

These questions are not intended to embarrass but are intended to help your counselor/case manager discuss with you these high-risk practices which have been shown to increase the risk of HIV/AIDS, and also to help you decide whether you wish to receive an HIV test.

1. Have you ever used a needle to take drugs, including steroids, either intravenously (IV), intramuscularly (IM) or subcutaneously (Sub-Q) or skin-popping? Yes No
2. Have you ever shared needles or works with anyone? Yes No
3. Have you ever forgotten what you did when you were high? Yes No
4. Have you ever had sex while you were high? Yes No
5. Have you ever engaged in sex, willingly or unwillingly, while you were in jail or prison? Yes No
6. Have you ever exchanged money or drugs for sex? Yes No
7. Have you had more than one sex partner in the past year? Yes No
8. Did you receive a blood transfusion or blood products between 1977 and 1985? Yes No
9. Have you ever had Herpes, Hepatitis B, Syphilis, Gonorrhea, Chlamydia, or sores on the sex organs? Yes No
10. Have you ever shared works or a needle with someone you now know is HIV positive or has AIDS? Yes No
11. For men only – Have you ever had male to male sex? Yes No N/A
12. Have you ever had sex with anyone who would answer YES to any of the above questions? Yes No
13. Do you think you have Tuberculosis (TB)? Yes No
14. Have you ever tested positive on a skin test for Tuberculosis? Yes No
15. Have you experienced any of the following symptoms within the past three months?
    • Frequent cough lasting more than two weeks? Yes No
    • Coughing up blood? Yes No
    • Night sweats? Yes No
    • Weight loss? Yes No
    • Loss of appetite? Yes No
    • Fever? Yes No
    • Fatigue? Yes No
16. Do you want to be tested for HIV? Yes No
17. Do you have any kind of lung disease? Yes No

The absence of any reported symptoms (all NO answers) clears the way for further routine intake procedures. The presence of any reported symptoms (all YES or UNSURE answers, except #4) requires further evaluation, see and follow instructions on bottom of this page. The presence of any signs or symptoms suggestive of TB requires further evaluation. In this Center, issue the patient the NIOSH approved facemask and ask him or her to wear the mask until seen by the physician. Instruct the patient to use the tissues provided and cover his/her mouth and nose when coughing or sneezing if he/she must remove the mask when coughing or Sneezing. Promptly present the patient to the physician for evaluation and admissions processes, ahead of any other patients, by informing the physician of the possible suspicion of TB and your precautions. If the patient is admitted to treatment he or she must receive an immediate Mantoux PPD skin test with instructions for reading the skin test within one to three days. If the Mantoux PPD test indicates a negative reaction, routinely schedule the patient for his or her second Mantoux PPD test.If the Mantoux PPD test indicates a positive reaction, immediately refer the patient to the health department or his or her family physician for determinations of infectious status. Treat any such patient as potentially infectious by referring to and following the required actions found in the TB Control Plan in the Policy and Procedures Manual.

According to the FDA, “Methadone may be expected to have additive effects when used in conjunction with alcohol, other opioids or CNS depressants, or with illicit drugs that cause central nervous system depression. Deaths have been reported when Methadone has been abused in conjunction with benzodiazepines.”

I have read the above information and I understand the risks and/or contraindications of mixing alcohol and benzodiazepines with Methadone.

Mixed agonist/antagonist medications, partial agonist medications and antagonist medications must not be used as they will precipitate opiate withdrawal syndrome.

• Mixed Agonist/Antagonist Medications:
• Pentazocine (Talwin)
• Butorphanol (Stadol)
• Nalbuphine (Nubain)

• Partial Agonist Medications:
• Buprenorphine (Subutex)
• Buprenorphine/Naloxone (Suboxone)

• Antagonist Medications:
• Naltrexone (Revia, Vivitrol)
• Naloxone (Narcan)

• Other Considerations:
• Meperidine and Propoxyphene should also be avoided due to potential risk of seizures.
• There have been individual case reports indicating that Ultram/Ultracet may cause opiate withdrawal.

• Date: 11/19/2025
• Patient Name:
• Date of Birth:
• Patient State ID or Driver's License number:

Authorize: to disclose my photograph and demographic information (Name, Alias, last 4 digits SSN, gender, DOB, admit date, Medication (type, form and dose), discharge date, reason, and last dose of medication) for admission to all Medication Assisted Treatment Programs, including programs that open in the future, within the state of Missouri and any other state that participates in the Central Registry. The information will be shared via secured electronic transmission.

The purpose for such disclosure is to prevent my dual enrollment in other OTP as well as provide assistance to treatment facility staff when they are providing emergency medication services during a disaster. This consent for disclosure is in compliance with Federal Confidentiality Laws (Federal Register, Vol. 4-Number 127, or July 1, 1975 subpart 2.31, 2.34) and 65D-30 and as amended.

I hereby specifically authorize this clinic, known as: I hereby authorize the above clinic to disclose the above described information as permitted by State Law to The Central Registry. I further authorize The Central Registry to transmit and disclose the above described information to any clinic that I may be enrolled to prevent my dual enrollment. I further authorize the use of information held in the Central Registry to assist me in times of emergencies/disasters to receive medication elsewhere should the clinic listed above be forced to Close.

By placing a checkmark next to "I Agree" after each of the following statements and my signature on this form, I confirm my understanding and acceptance of the following:

I understand my records are protected under the Federal Confidentiality Regulations and may not be disclosed without my express written consent, unless otherwise provided for in the regulations. I also understand I may revoke this consent at any time except to the extent that action has been taken in accordance with it, and in any event, this consent expires automatically as set forth below.
I Agree

I understand the above information will be maintained in the Lighthouse Software Systems, LLC (“LHSS”) central registry system for purposes of my participation in a Central Registry within this state named above, and also for the purpose of aiding my care in times of disaster and dual enrollment verification to prevent multiple medication assisted treatment program enrollments. LHSS is located at 17352 Derian Ave, Irvine, CA 92614. The Central Registry will contain presently prescribed medication(s) used for my treatment and my schedule of dosing records. This information will reside in the LHSS Central Registry system while I remain a patient at this clinic and will be available to staff where I may present for admission or emergency medication services for up to 60 days after my discharge from treatment at this location. My name will be encrypted in the LHSS Central Registry System database with technology that will meet HIPAA compliance requirements.
I Agree

I understand when any clinic which participates in the Central Registry requests information from the Central Registry and I am found to be enrolled in another clinic, the Central Registry will disclose the name, address, and telephone number of the clinic in which I am already enrolled to the requesting clinic.
I Agree

I understand this is a limited disclosure for the purpose or purposes as stipulated above, and so indicated by the person whose records this information has been extracted from. “This information has been released and disclosed to you from records whose confidentiality is protected by Federal Regulations (42 CFR Part 2) and the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 C.F.R. parts 160 and 164 which prohibit you from making any further disclosure of it without the specific written consent of the person to whom it pertains, or as otherwise permitted by such regulations. A general authorization for the release of Medical or other information is NOT sufficient for this purpose.”
I Agree

I understand my consent is automatically revoked 60 days after my discharge.
I Agree

I understand I may view and request a copy of the information described above and/ or in this form.
I Agree

I understand this treatment facility named above gets no compensation from LHSS for using or disclosing health information noted above.
I Agree

I voluntarily consent to have my mobile number be used by treatment facility staff to notify me through the Central Registry’s communication module to notify me about service disruptions and treatment reminder information.
I Agree

I voluntarily consent to have my email be used by treatment facility staff to notify me through the Central Registry’s communication module to notify me about service disruptions and treatment reminder information.
I Agree

I understand that the State may require additional information to be collected about me and entered into the Central Registry including but not limited to race, ethnicity and funding source.
I Agree

This program is required to notify each patient prior to admission that it cannot provide treatment or medication to a patient who is simultaneously receiving these same services from another treatment program unless the medication is being provided in response to an emergency or disaster that forced the closure of the patient’s regular home clinic.

I am not receiving medication and/or treatment from another Medication Assisted Treatment facility, its satellite or an Office Based Opioid Treatment provider and I understand if I do not sign this statement I will not be admitted for treatment or provided emergency medication services.

I understand I might be denied treatment if I refuse to consent to a disclosure for purposes of this Central Registry, if permitted by state law. I will not be denied services if I refuse to consent to disclosure for other purposes. I also hereby release the OTP stated above from liability which may arise as a result of information disclosed under an authorization if such information disclosed is later used to my detriment.

I was offered a copy of the release of information and at this time: I accept a copy of the release of information I decline a copy of the release of information

** In the case of patients who are deceased, have been judged incompetent or otherwise unable to sign on their own behalf, please have the authorized representative sign here:

The Central Registry is operated by Lighthouse Software Systems, LLC., located at 17352 Derian Ave., Irvine, CA 92614. Lighthouse will not send any promotional, marketing or solicitation messages to you. Lighthouse will not sell, share or use your contact information for any purpose other than messages sent by your treatment provider. By providing your mobile number, you agree the Lighthouse Software Systems, LLC may send you periodic SMS or MMS messages containing but not limited to important clinic information generated by your PTO/NTP.

I understand that by voluntarily providing my mobile number and/or email address, I opt-in and agree to receive communications from The Central Registry on behalf of my treatment provider, .

I understand and hereby authorize my treatment provider to send messages from The Central Registry to me for a variety of purposes, including but not limited to:

• Service disruption notifications
• Emergency closures
• Appointment reminders
• Counseling/counselor reminders

I understand that the following data may be collected:

• My mobile phone number
• My mobile service provider’s number
• My email address
• Date and time of messages sent to me
• Content of messages sent to me

• Current Phone Number:
• Current Email:

• Message frequency will vary
• You may unsubscribe at any time by texting the word STOP to (239)341-7182. You will receive a subsequent message confirming your opt-out request.
• For help, send the word HELP to (239)341-7182 or email info@centralregistry.com.
• Message and data rates may apply
• United States Participating Carriers Include AT&T, T-Mobile®, Verizon Wireless, Sprint, Boost, U.S. Cellular®, MetroPCS®, InterOp, Cellcom, C Spire Wireless, Cricket, Virgin Mobile and others.
• U.S. based carriers are not liable for delayed or undelivered messages.
• You agree to notify us of any changes to your mobile number and update your account with us to reflect the change.
• Data obtained from you in connection with this SMS service may include your cell phone number, your carrier’s name, and the date, time and content of your messages, as well as other information that you provide. We may use this information to contact you and to provide the services you request from us.
• By subscribing or other using the service, you acknowledge and agree that we will have the right to change and/or terminate the service at any time, with or without cause and/or advance notice.

I, understand that I am responsible for the payment of all fees under this program and do hereby promise to pay for all such fees. If I am eligible for insurance, I understand it is my responsibility to maintain my eligibility status. I am responsible to make the appropriate co-pays at the time of service and are responsible for any deductible amount required by the insurance plan. I further acknowledge that if my insurance carrier fails to pay and/or denies any services, I am responsible for payment. If my account for any unpaid fees or other charges is referred for collection, I agree to pay any and all attorney’s fees, collection fees, and court costs related to the collection of my account. Pursuant to Confidentiality of Substance Use Disorder Patient Records, 42 C.F.R., Part 2, I authorize Colonial Management Group, L.P. d/b/a New Season Treatment Centers (hereinafter "New Season") to disclose my name and any of my records to any outside party and/or collection agency that may be needed or required to pursue collection of any delinquent monies I am responsible for and further authorize the outside party and/or collection agency to utilize those records, as they may require to collect any delinquent monies which I owe to New Season.

I acknowledge treatment fees have been explained to me. I also understand that these fees are subject to change or adjustment over time.

Clinic Fees, as applicable:

• Intake: None
• Intensive Outpatient Program: Talk to your treatment team for more information.
• Additional Urine Drug Screen: $10
• Confirmation Urine Drug Screen: $ 35
• Monthly Surcharge: None
• Oral Swab: $10

Daily Medication Fees, as applicable:

• Methadone Liquid: Please select a location above.
• Methadone Tablet: Please select a location above.
• Buprenorphine: Please select a location above.
• Suboxone: Please select a location above.

I acknowledge and accept all terms and conditions related to the payment of the fees under my treatment.

I understand that I will be required to submit to periodic drug screens as required by state and federal rules, for the purposes of determining drug use.I understand the following rules apply:

1. I am expected to provide a drug screen sample upon request of any staff member. Daily medication dosage may be delayed until a sample is produced.
2. I understand that I will be requested to submit to a drug screen on a random or unscheduled basis but at least once a month or more often as necessary, sometimes on a weekly basis.
3. I understand that a refusal on my part to provide a sample shall count as a positive drug screen and may result in loss of privileges.
4. I understand that a drug screen which contains a foreign matter or substance will be considered a positive drug screen and may result in loss of privileges. Evidence of dilution will also be considered positive.
5. I understand that a cold bottle of urine shall count as a positive drug screen and may result in loss of privileges.
6. I understand that purses, bags, jackets or heavy clothing will not be permitted in the restroom.
7. I understand that a same-sex staff member may observe me as I produce a urine sample, and that a refusal to cooperate may result in loss of privileges.
8. An attempt, whether successful or not, to defeat or cheat on urinalysis testing may result in loss of privileges.

I understand and consent to these rules and agree to abide by them as a condition of my treatment.

Patient Name:

I acknowledge and affirm that I understand the services offered by this medical treatment facility:

1. This medical treatment facility offers methadone maintenance and detoxification for opiate addiction. Patients receive individually prescribed methadone medication from a licensed medical staff member. The methadone treatment program is staffed by employees from various professions including physicians, licensed practical nurses, pharmacists, and drug and alcohol counselors
2. The clinic offers healthcare services including physical examinations and testing for TB, HIV, and Hepatitis-B
3. Patients meet with a primary counselor for individual counseling, at minimum monthly. Patients will attend group counseling as outlined in their treatment plan. Family counseling is available as requested
4. Patients receive case management services to access social services and referrals for vocational, educational, medical, family, legal, financial and psychiatric problems
5. The clinic offers assessment and individual treatment planning services to address biopsychosocial, substance abuse and life needs
6. This medical treatment facility provides the patient suffering from opiate addiction with health, social and rehabilitation services alongside medically prescribed medications to relieve withdrawal symptoms and reduce opiate cravings
7. The medication treatment facility offers monthly urinalysis and referral to various support and self-help groups individualized to the patients needs

Besides the possible risks involved with the long-term use of opioid agonist medication, I further understand that the safety and effectiveness of opioid agonist medication treatment during pregnancy is well established, however it remains inadequate to guarantee that significant or serious side effects will not occur.

I understand that opioid agonist medication is transmitted to the unborn child and will cause physical dependence during the pregnancy and possible newborn withdrawal following delivery. Thus, if I am pregnant and suddenly stop taking opioid agonist medication, the unborn child may show signs of withdrawal, which may adversely affect my pregnancy or the child. I shall use no other drugs without approval of the Medical Director or their authorized assistant since these drugs, particularly as they might interact with opioid agonist medication, may harm me or my unborn child. I shall inform any other physician who sees me during the present or any future pregnancy, or who sees the child after birth, of my current or past participation in a narcotic treatment program in order that they may properly care for my child and me.

I understand that after the birth of my child that chest-feeding/breast-feeding is safe and encouraged provided there are no other medical reasons to avoid nursing the newborn. I understand that for a brief period following the birth, the child may show temporary irritability or other signs or symptoms of newborn withdrawal associated with the abrupt discontinuation (delivery) of opioid agonist medication. It is essential for the child's physician to know of my participation in a narcotic treatment program so that they may provide appropriate medical treatment for the child.

All the above possible effects of opioid agonist medication have been explained to me, and I understand that at present, studies conducted on the long-term use of the drug fail to ensure complete safety to my child. With full knowledge of this, I consent to its use and promise to inform the Medical Director or one of their assistants immediately if I become pregnant.

I certify that no guarantee or assurance has been made as to the results that may be obtained from narcotic addiction treatment. With full knowledge of the potential benefits and possible risks involved, I consent to narcotic treatment, since I realize that I would otherwise continue to be dependent on heroin or other narcotic drugs.

Patients who are pregnant or may become pregnant during treatment are required to meet the same financial obligations as other non-pregnant patients.

1. Pregnancy does not change your financial obligations to New Season.
2. Pregnant patients who fail to meet the clinic’s financial obligations will be provided with an individualized and medically supervised withdrawal (MSW) which shall be initiated upon consultation with your attending obstetrician.
3. Your attending obstetrician will be informed in writing that you are being gradually withdrawn from opioid agonist medication maintenance.
4. The safety of medically supervised withdrawal during pregnancy has been established with clinical experience as an evidencebased optional procedure.
5. During medically supervised withdrawal, New Season will cooperate with your efforts to arrange for alternative care, including transfer to another opioid treatment program (OTP).