Consent & Release Form
Please read and sign below and a copy will be emailed to you.
ANGER MANAGEMENT EVALUATION CONSENT AND RELEASE FORM
I, the undersigned, hereby authorize Cornerstone Recovery Coaching (herein referred to as, CRC) to order an Anger Management Assessment / Evaluation.
The information contained in the Anger Management Assessment / Evaluation is necessary for: Anger Management Diagnosis, Recommendations, Treatment and / or for Legal Purposes, or Information Collateral to the Anger Management Assessment / Evaluation.
The individual signing this release agrees that he/she has received and read the specific requirements from their county in regard to the Anger Mgt., evaluation or assessment. “I acknowledge that I am aware of all said requirements and the details described therein, inclusive of specifics for multiple offences and will convey this information to my counselor at CRC.
I am aware that I need to submit any and all documentation of current and prior charges and/or arrests that I have had throughout my lifetime, if any, and that these must match what is currently held within my court records. By ordering this Anger Management Assessment / Evaluation, I agree and confirm my authorization to CRC to assist in obtaining any and all necessary information, reports and records necessary to conduct this evaluation / assessment thoroughly through various means inclusive of, but not limited too; background checks, police reports, criminal records, and other various available reports.
I acknowledge that it is my responsibility to submit this evaluation/assessment to the requesting party, unless prior written release has been agreed between self and CRC. CRC is in no way responsible for delivery or submission to any other party without this prior written notice as outlined in HIPAA compliance rules.
I agree that the answers I provide on the assessment / evaluation and all corresponding paperwork are true and accurate to the best of my knowledge. I have included alI available pertinent and associated legal documentation as stated prior and I acknowledge that my current documentation is original and suitable for state / federal court related anger management and alcohol & drug evaluations and covers all states I need cleared. I understand and agree that CRC will not complete my assessment / evaluation unless submission of all required documentation has been met.
I understand that CRC will not refund any evaluations that are denied due to inaccuracies, false testament, non-rendered or misleading information. I have read my rights and I under-stand that CRC and any of their representatives are Certified Anger Management Personnel, Certified Alcohol and Drug Counselors and Facilitators and are not licensed Medical Physicians and cannot give me a formal diagnosis on my medical, physical or emotional health.
*You have the right to reject the completed anger management evaluation at your own costs, to withdraw from the process at any time, or to seek a second opinion by obtaining another evaluation. However, any information provided may be released to the Court or the Office of the Secretary of State, upon request. If the evaluation procedure is forfeited, not completed, paid in full, or abandoned, we may be required to send notice to the Court or the Office of the Secretary of State.