Adult Rights to Privacy

ADULT RIGHTS TO PRIVACY

EXCEPTIONS TO PRIVACY

SUBSTANCE ABUSE POLICY

Please read the five exceptions to privacy and the substance abuse policy before signing.

Five Exceptions to Privacy

1. New Jersey law requires our staff to report to the appropriate government agency any suspected physical, sexual, or emotional abuse or neglect.
2. If we learn that someone with whom we are working has a specific intent to bring harm to himself/herself, we reserve the right to inform other family members and/or make appropriate referrals if necessary.
3. If information is ordered by the court, including a subpoena, we will attempt to contact you about the order. If you oppose the release, the court may nevertheless require compliance with the order.
4. If we learn that someone participating in the program might commit a violent act, we may take steps to protect the intended victim against such danger or inform police, or both.
5. The rights and exceptions to privacy apply to information disclosed in support groups. All group members are encouraged to keep such information confidential, but the Center cannot guarantee that they will do so.

*** Anyone under the influence of drugs or alcohol will be made to leave the premises.***

In signing this document, I acknowledge that I have had the opportunity to ask questions about The Alcove Center’s Confidentiality Policy. I have read and understand the “right to privacy and exceptions to privacy” information. I have read the substance abuse policy. I fully understand and accept my rights to privacy , the exceptions to privacy, and the substance abuse policy.

Today’s Date _____________________

Printed Name_____________________________

Signature ___________________________

Revised 7/26/12