ADSAC Assessment Forms and Payment Link: Informed Consent

An alcohol and drug assessment consists of a face-to-face clinical interview, at least two (2) testing instruments (a DRI or DQ and a TAAD, MAPP, NEEDS or JASAE), a biopsychosocial interview (ASI) and a closing summary in which the scoring of the tests, the conclusions and interpretations are presented to you so that you will understand the results of the assessment.

You have the right to understand the results of your testing and assessment, and how it will affect you. These assessment results will determine the level of education, treatment, or both, as part of the set of recommendations for reinstatement of your driving privileges and (if applicable) your court order.

This testing and assessment process is not a pass or fail process. There are no right or wrong answers, but to be accurately assessed, you need to be open and truthful in your responses. Your information is protected under Federal and State Law, which cannot be released without your written permission and may not be used to criminally prosecute you other than certain exceptions (including child abuse, elder abuse, medical emergency, and threats of harm to yourself or another person.) The process is intended to give you the right combination of services to help you avoid similar problems in the future.

 This assessment process will take some time; about (2) to (3) hours. If you have problems with reading or comprehension, it may take longer. We will assist you as much as we can. Be sure to bring your reading glasses if you need them.

If you are under the influence of alcohol or other drugs at the time of your appointment for testing and assessment, you will be asked to make another appointment.

Your assessment testing and assessment documentation will be kept in this office for (6) years. If during that time you need another release of information, contact our office for help. Releases are only valid for (1) year.

Information verifying completion of the process will be forwarded to the Oklahoma Department of Public Safety through the Oklahoma Department of Mental Health and Substance Abuse Services.

1.) I have read the information listed above and understand the cost of the assessment, the purposes of the assessment, and the time involved. I understand that my truthfulness and honesty will produce the most accurate results. I understand that the results of the assessment may determine other requirements for reinstatement of my driving privileges and (if applicable) to satisfy my court requirements.

2. ) I understand that according to OAC Title 450:22, that my assessment will remain valid for six (6) months from the date of completion. If after six (6) months, I have not taken any action toward initiating my assessment recommendations, the assessment shall be considered invalid and a new assessment is required.

By signing below, I certify that I have read and understand the information contained in this consent form and I give my consent for Misti Luke, LCSW to perform my assessment.

I, Misti Luke am required by Oklahoma Administrative Code to furnish and allow you to review this document of disclosure of my DUI assessor certification. I am certified by the Oklahoma State Department of Mental Health and Substance Abuse Services as a State Certified Substance Abuse (ADSAC) Assessor. 

My state  ADSAC Assessor certification number is #3041.

You may contact my program administrator at:

OK Dept. of Mental Health and Substance Abuse Services : ADSAC Programs 

2000 Classen Blvd. 2-600  Oklahoma City, OK 73106  

Telephone:  (405) 248-9027   Fax: (405) 248-9324                             

LICENSES OR CERTIFICATIONS

In addition, if professionally licensed or certified, I am required by Oklahoma law to inform you of my professional training, experience, fees, and credentials. I am certified to practice my profession by the state of Oklahoma.

 

I am a:       1.) Licensed Clinical Social Worker: License #4249

                  2.) ADSAC DUI Facilitator: #3655

                  3.) Batterer Intervention Program (BIP) Facilitator

 

I will furnish you with printed materials about the requirements of my license if you so desire. You may contact (without giving your name) the Professional  Licensing Organization or Certification Organization at:

Oklahoma State Board of Licensed Social Workers, 3700 Classen Blvd, Suite 162 Oklahoma City, OK 73118  Phone: (405) 521-3715

Oklahoma Dept. of Mental Health & Substance Abuse services/ADSAC 2000 N. Classen Blvd 2-600 Oklahoma City, OK 73106  Phone: (405) 248-9200

 

My signature below indicated I have read and understand the contents of this document. Furtermore, the above designated assessor has satisfactorily supplied me with the information regarding her license, professional credentials and certifications.

 

My signature below indicates all the information above is correct and true to the best of my knowledge. 

From the Oklahoma Department of Mental Health and Substance Abuse Services:

Each consumer has the right to be treated with respect and dignity. Furthermore: Each consumer shall retain all rights, benefits, and privileges guaranteed by law except those lost through due process of law. Each consumer has the right to receive services suited to his or her condition in a safe, sanitary and humane treatment environment regardless of race, religion, gender, ethnicity, age, degree of disability, handicapping condition or sexual orientation. No consumer shall be neglected or sexually, physically, verbally, or otherwise abused. Each consumer shall be provided with prompt, competent, and appropriate treatment; and an individualized treatment plan. A consumer shall participate in his or her treatment programs and may consent or refuse to consent to the proposed treatment. The right to consent or refuse to consent may be abridged for those consumers adjudged incompetent by a court of competent jurisdiction and in emergency situations as defined by law.

Additionally, each consumer shall have the right to the following: Allow other individuals of the consumer's choice participate in the consumer's treatment and with the consumer's consent; To be free from unnecessary, inappropriate, or excessive treatment; To participate in consumer's own treatment planning; To receive treatment for co-occurring disorders if present; To not be subject to unnecessary, inappropriate, or unsafe termination from treatment; and To not be discharged for displaying symptoms of the consumer's disorder. Every consumer's record shall be treated in a confidential manner.  No consumer shall be required to participate in any research project or medical experiment without his or her informed consent as defined by law. Refusal to participate shall not affect the services available to the consumer. A consumer shall have the right to assert grievances with respect to an alleged infringement on his or her rights.

 

Each consumer has the right to request the opinion of an outside medical or psychiatric consultant at his or her own expense or a right to an internal consultation upon request at no expense. No consumer shall be retaliated against or subjected to any adverse change of conditions or treatment because the consumer asserted his or her rights.

 

ODMHSAS: Office of Consumer Advocacy, E-Mail: AdvocacyDivision@odmhsas.org Local: (405) 248-9037 Toll Free: (866) 699-6605, Reachout Hotline (800) 522-9054

 

My signature indicates I have read and understand my rights and have been offered a copy of this document.

 A consumer shall have the right to assert grievances with respect to an alleged infringement on his or her rights. Each consumer has the right to request the opinion of an outside medical or psychiatric consultant at his or her own expense or a right to an internal consultation upon request at no expense. No consumer shall be retaliated against or subjected to any adverse change of conditions or treatment because the consumer asserted his or her rights. As stated above, the consumer has the right to voice grievances regarding treatment or care that is (or fails to be) furnished, or regarding the lack of respect for person and/or property and will not be subjected to discrimination or reprisal for so doing. 

If the consumer feels that he or she has a grievance, he/she/they can complete a grievance orally or in writing with Step Three, Inc. He/she/they has the right to seek a review thereof with the Director, Misti Luke.  A memorandum of the grievance will also be made by the Director, Misti Luke. The grievance should specify any objections or disagreements which the consumer has of Step Three, Inc. Every attempt will be made to resolve the grievance. Should the grievance be resolved, a written report of the actions to alleviate the aggrieved will be provided to the aggrieved consumer. Should the aggrieved consumer not be satisfied with the resolution, the grievance shall be forwarded to the Board of Directors by the Director, with staff recommendations for resolution. In any event, the recommended resolution shall be provided to the aggrieved patient within one week of receiving the written grievance. Contact information for the Board of Directors is posted in the lobby of the Broken Bow office.

In addition to the above, the consumer also has a right to file a grievance with or without the knowledge of Step Three, Inc, or its staff, to the Department of Mental Health and Substance Abuse Services (ODMHSAS) by contacting the Patient Advocacy Division either telephonically or in writing. Contact the ODMHSAS Patient Advocacy Division at: 

ODMHSAS Patient Advocacy Division 2401 NW 23rd Oklahoma City Ok 73107 1-866-699-6605 advocacydivision@odmhsas.org  No adverse consequences or reprisals will be experienced by any persons filing a grievance or complaint against Step Three, Inc. 

 

ODMHSAS: Office of Consumer Advocacy, E-Mail: AdvocacyDivision@odmhsas.org

Local: (405) 248-9037 Toll Free: (866) 699-6605  Reachout Hotline (800) 522-9054

 

My signature indicates I have read and understand my rights to file a grievance and have been offered a copy of this document.

Step Three, Inc shall meet the requirements of all applicable state and federal laws, rules, and regulations.  Patient records are considered confidential and will not be released to another induvial or agency without your expressed written consent, except upon receipt of a legitimate subpoena, in the event of a valid medical emergency, to meet the requirements of state law that child/elderly abuse be reported or in the event you present an imminent danger to yourself or others.

The confidentiality of all ADSAC information and records (including all ADSAC participant and course records, shall be kept, recorded, released, maintained, and provided to requesting parties in accordance with all applicable state and federal laws.

b) For the purposes of certification, all institutions, organizations and facilitators will abide by 42CFR, Part 2 as required for covered entities protecting the confidential and privileged nature of information in compliance with state and federal law and which requires at a minimum:

(1) all ADSAC course information, whether recorded or not, and all communications between institution and organization staff, facilitators and participant are both privileged and confidential and will not be released without the signed consent of the participant or the participant’s legally authorized representatives:

(2) the identity of a participant who has received or is receiving ADSAC services is both confidential and privileged and will not be released without the signed consent of the participant or the participant’s legally authorized representative;

(3) limiting access to ADSAC course and participant information to only those persons or agencies actively engaged in the treatment of the participant and to the minimum amount of information necessary to carry out the purpose for the release;

(4) a participant or the participant’s legally authorized representative may access the participant’s ADSAC court information;

(5) certain state and federal law exceptions to disclosure of ADSAC course information without the signed consent of the participant or the participant’s legally authorized representative exist and the facility will release information as required by those laws, and; 

(6) notifying a participant of his or her right to confidentiality in writing.

 

My signature below indicates I have read and understand the contents of this document.