Drug Authorization & Consent (Rev 20210325) Drug Authorization & Consent (Rev 2020-08-08) DRUG TESTING AUTHORIZATION & CONSENT I, the undersigned parent/guardian, hereby knowingly and voluntarily authorize and consent for my child to participate in the collection and testing of specimens of my child's urine by Child and Family Agency for the purpose of drug testing. I, the undersigned client, hereby knowingly and voluntarily authorize and consent to participate in the collection and testing of specimens of my urine by Child and Family Agency for the purpose of drug testing. I acknowledge that drug tests may happen at random and will occur at the discretion of the clinician. I acknowledge that the drug test results will not be shared with outside agencies by Child and Family Agency. I further acknowledge that results of the drug test will be discussed in session with family members for the purpose of treatment. I recognize that no action will be taken against me by Child and Family Agency as a result of a positive drug test. I acknowledge that I have the right to receive a copy of this authorization. I have read and understood the above Authorization & Consent in its entirety, and I agree that a copy of this document is as valid as the original. Agreement to consent to drug testing* (client under 18 years old) I hereby state that I am the legal guardian of the following child, and I have the authority to consent to the collection and testing by Child and Family Agency for the purpose of drug testing. (client 18+ years old) I hereby consent to participate in the collection and testing of specimens of my urine by Child and Family Agency for the purpose of drug testing. Client/Guardian declined Client name* First Last Client date of birth* MM slash DD slash YYYY Parent/Guardian Signature* Today's date* MM slash DD slash YYYY Client Signature* Client date of birth* MM slash DD slash YYYY Today's date* MM slash DD slash YYYY Client name* First Last Client date of birth* MM slash DD slash YYYY Program* Today's date* MM slash DD slash YYYY Client/Guardian signature*
