Grievance Procedures – If you feel at any time that your rights to services have been

violated or you are dissatisfied with the services you are getting, you may appeal in
writing to the Contra Costa County Alcohol and Other Drugs Services Administration,
597 Center Avenue, Suite #320, Martinez, CA, 94553. If this appeal is denied, a
further appeal may be made in writing to the Complaint Coordinator, Department of
Alcohol and Drug Programs, 1700 K Street, Sacramento, CA, 95814 or by calling
(916) 327-3723.
Statement of Consumer Confidentiality – No information about a current or
previous consumer can be released without prior written consent of the consumer or
former consumer except in the following situations required by law: (a) Persons under
the influence of alcohol and other drugs; (b) Child abuse or neglect; (c) Danger to self
and others; (d) Possession of weapons or other dangerous objects; (e) Emergency
interventions; (f) Possession of alcohol and other drugs;
(g) Sale of alcohol and other drugs.

I understand that the information to be released from my records is confidential and

cannot be disclosed without my written consent unless otherwise mandated by law
Compliance with 42 CFR, Part 2, Article 7, Section 5325 of Subchapter 2, Part I of
Division 5 of the Welfare and Institution Code. I understand that I may revoke this
authorization at any time, except to the extent that action has already been taken to
comply with it. I do not void this authorization, it will automatically expire in 6
months from the date I signed it.

Consent for Consumer Follow-up – After you have completed the POWER program,
staff would like to follow-up on your progress 6 months and 12 months after
discharge.
I do consent________to follow up contacts after discharge or termination.
I don’t consent_____to follow up contacts after discharge or termination.
Acknowledgement
I have read and understand all of the above. I have also received a copy of this
document. I hereby consent to participate in the POWER program services and abide
program rules. I have also read and understand my rights and responsibility as a
consumer or participant in these services.

Consumer Name____________________ Signature ___________Date____________

Legal Guardian Name________________Signature____________Date____________

Counselor Name____________________ Signature___________ Date____________