Drug / Alcohol Testing Consent Form

Please enter your full name, exactly as it is recorded in the application.

First Name:
Client first name

Middle Name:
Client middle name

Last Name:
Client last name

I hereby consent, upon the request of Be Able staff, to furnish a sample of my urine, breath and/or blood for analysis for a drug and alcohol test. I am fully aware that the results of this test will be retained by Be Able and will become part of my record.
Checkboxes

I agree to having authorized personnel (l.e. Housing Director, House Lead and/or assigned Mentor) monitor me during the process of providing the urine sample.
Checkboxes

I understand that if at any time I refuse to submit to a drug or alcohol test, or if I otherwise fail to cooperate with the testing procedures, it will count as a failed test and discipline action may be taken.
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_________________________ 

Signature:
Signature

Date:
Date