As a participant in BrightView’s addiction treatment program, I freely and voluntarily agree to accept the terms and conditions of this agreement:
I agree to keep and be on time for all my appointments. (Most appointments can be made within 24 hours and sometimes patients can be seen on the same day.) If I miss my scheduled appointment, I must call within 24 hours to reschedule.
I agree to conduct myself in a courteous manner in the BrightView offices. I agree not to conduct any illegal or disruptive activities in the BrightView outpatient treatment facilities.
I agree not to sell, share, or give any of my medication to another person. I understand that such mishandling of my medication is a serious violation of this agreement and could negatively impact me.
I understand that if I am observed or suspected of dealing, stealing, or performing an illegal or disruptive activity by an employee of the pharmacy where my medication is filled, that the behavior will be reported to BrightView and could negatively impact me.
I understand that a missed scheduled physician’s visit will result in a charge.
I will provide a legally issued ID card, driver’s license, state issued ID card, or passport. (No other method is acceptable.)
I understand that payments may be made in the form of cash, credit or debit card.
I agree that my medication/prescription can only be given to me at my regular office visits. A missed visit may result in not getting my medication/prescription until the next scheduled visit.
I agree that the medication I receive is my responsibility and I agree to keep it in a safe and secure place. I agree that lost medication will not be replaced regardless of why it was lost. (Brightview will not call in any refills for any medications that have been lost, stolen, destroyed or misplaced— no exceptions will be made.)
The safekeeping of my prescriptions is solely my responsibility.
I agree not to obtain medications from any physicians, pharmacies, health care providers or other sources without telling my BrightView treating physician. (BrightView has a zero-tolerance policy for “physician shopping,” and reports of falsified prescriptions or modified prescriptions will result in immediate discharge from the outpatient program.)
I understand that mixing Suboxone (Subutex®/buprenorphine/Naloxone®) with other medications especially benzodiazepines (e.g. Valium®, Klonopin®, or Xanax®) can be dangerous. I also recognize that several deaths have occurred among persons mixing buprenorphine (Subutex®/buprenorphine/Naloxone®) and benzodiazepines (especially if taken outside the care of a physician or using routes of administration other than sublingual or in higher than recommended therapeutic doses).
I agree to take my medication as the BrightView treating physician has instructed and not to alter the way I take my medication without first consulting my BrightView treating physician.
I understand medication alone is not sufficient treatment for my condition, and I agree to consider other forms of treatment including counseling and substance abuse support groups.
I agree to abstain from alcohol, opioids, marijuana, cocaine, and other addictive substances (except nicotine and caffeine).
I agree to provide a urine sample for drug testing at intake and as requested thereafter and to have my blood alcohol level tested. If I test positive for opiates or other controlled substances I may be put on a more frequent visit schedule until the physician no longer deems it necessary.
I understand a violation of any of the above items may be grounds for discharge of my treatment in the sole absolute discretion of the ARNP, Medical Staff, Clinical Directors, or Executive Staff.
No refunds for advance payments shall be made. Patients may be reinstated without penalty at the discretion of the Medical Director and/or Clinical Staff. Reinstatement is not a guarantee. However, additional services and expenses may be assessed if necessary. After 30 days of discharge from the program, patients must re-start the program.
For patients admitted into the program, patients must re-start the program if they have missed more than 7 consecutive days, or as directed by the Medical Director.
IT IS ALSO YOUR RESPONSIBILITY TO:
Maintain your sobriety while receiving services at the BrightView treatment center. Anyone who appears to be or proves to be under the influence of alcohol or drugs will be excluded from the group session.
Refrain from using any type of chemical substance while in treatment unless approved by a physician.
Cooperate and conduct yourself in a responsible and appropriate manner. Physical violence or threats of violence are grounds for discharge. You will also meet your probation officer monthly, if applicable.
Be on time for all sessions. All therapy sessions will begin promptly at the designated time. Failure to be on time will result in a case conference to determine necessary action.
Respect and protect the confidentiality of others. Also, respect the property of others.
Resolve grievances as outlined in the Patient’s Rights Policy.
Agree to pay the plan specified by BrightView.
Subject to applicable State and Federal law, BrightView will comply with the following Patient rights established by the Ohio Department of Mental Health and the State of Ohio Department of Alcohol and Drug Addiction Services to the extent applicable to our program:
The right to be treated with consideration and respect for personal dignity, autonomy, and privacy;
The right to service in a humane setting, which is the least restrictively feasible as defined in the treatment plan;
The right to be informed of one’s own condition, of proposed or current services, treatment or therapies, and of the alternatives and of available prevention services;
The right to consent to or refuse any service, treatment, or therapy upon a full explanation of the expected consequences of such consent or refusal. A parent or legal guardian may consent to or refuse any service, treatment, or therapy on behalf of a minor Patient;
The right to a current, written, individualized service plan that addresses one’s own mental health, physical health, social and economic needs, and that specifies the provision of appropriate and adequate services, as available, either directly or by referral;
The right to active and informed participation in the establishment, periodic review, and reassessment of the service plan;
The right to freedom from unnecessary or excessive medication;
The right to freedom from unnecessary physical restraint or seclusion;
The right to participate in any appropriate and available agency service, regardless of refusal of one or more other services, treatments, or therapies, or regardless of relapse from earlier treatment in that or another service, unless there is a valid and specific reason which precludes and/or requires that Patient’s participation in other services. This necessity shall be explained to the Patient and written in the Patient’s current service plan;
The right to be informed of and refuse any unusual or hazardous treatment procedures;
The right to be advised of and refuse any observation by techniques such as one-way vision mirrors, tape recorders, televisions, movies or photographs;
The right to have the opportunity to consult with independent treatment specialists or legal counsel, at one’s own expense;
The right to confidentiality of communications and of all personally identifying information within the limitations and requirements for disclosure of various funding and/or certifying sources, state or federal statutes, unless release of information is specifically authorized by the Patient or parent or legal guardian of a minor Patient or court-appointed guardian of the person of an adult Patient in accordance with rule 3793:2-1-07 of the Ohio Administrative Code;
The right to have access to one’s own psychiatric, medical or other treatment records, unless access to particular identified items of information is specifically restricted for that individual Patient for clear treatment reasons in the Patient’s treatment plan. “Clear treatment reasons” shall be understood to mean only severe emotional damage to the Patient such that dangerous or self-injurious behavior is an imminent risk. The person restricting the information shall explain to the Patient and other persons authorized by the Patient the factual information about the individual Patient that necessitates the restriction. The restriction must be renewed at least annually to retain validity. Any person authorized by the Patient has unrestricted access to all information. Patients shall be informed in writing of agency policies and procedures for viewing or obtaining copies of personal records;
The right to be informed in advance of the reason(s) for discontinuance of service provision, and to be involved in planning for the consequences of that event;
The right to receive an explanation of the reasons for denial of services;
The right not to be discriminated against in the provision of service on the basis of religion, race, color, creed, sex, national origin, age, lifestyle, physical or mental handicap, developmental disability, sexual orientation, disability or HIV infection, whether symptomatic or asymptomatic of AIDS
The right to know the cost of services;
The right to be fully informed of all consumer rights;
The right to exercise any and all rights without reprisal in any form including continued and uncompromised access to service;
The right to file a grievance; and
The right to have oral and written instructions for filing a grievance.
CAUSES FOR DISMISSAL
Violation of various rehab program rules as described in this policy (60-day suspension)
Failure to return within 2 hours after prescription of buprenorphine/Naloxone is written (60-day suspension)
Non-compliance with medical protocol (60-day suspension)
Inappropriate behavior that places self or others in danger (60-day suspension)
Verbal or physical threats of violence against other patients or staff (120-day suspension)
Acts of violence (Revocation, the patient is not permitted reinstatement into the outpatient treatment program)
Harassment (verbal, social or sexual) against other patients or staff (Revocation, the patient is not permitted reinstatement into the program)
Trading, selling, buying or otherwise diverting any and all drugs (including those prescribed by a physician)
Need to leave the program for a medical or other mental health issue (Suspension to be determined by the Medical Director)
Find admission forms and a brief orientation to the program here.