Consent for Intervention and/or Treatment

hereby consent to receive Intervention services and/or Treatment services from Right Direction Services, LLC.

RIGHT DIRECTION SERVICES LLC

7210 E State Street, Suite 102 Rockford IL 61108

I consent to the use or disclosure of my protected health information by Right Direction Services, LLC for the purpose of my care, as well as for obtaining any referrals to a treatment provider.

By signing this Client Information and Consent Form as the Client or Guardian/Parent of said Client, I acknowledge that I have read, understand, and agree to the terms and conditions contained in this form, in the Client Rights document, and rules for participation documents that have been provided to me. I acknowledge that I have been provided with these documents and have been given an appropriate opportunity to address any questions or request clarification for anything that is unclear to me. I am voluntarily agreeing to receive Intervention services and/or Treatment from Counselors at Right Direction Services, LLC.

I understand I have the right to considerate, safe and respectful care, without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion, national origin, or source of payment. I understand I have the right to ask questions about any aspects of my care.

Consent / Acknowldgements

Participation in the Driving-Under-the-Influence (DUI) Program services through online telehealth Internet technology is entirely voluntary. You are not required to participate in the DUI Program services through this telehealth option.

The telehealth ZOOM tele-conferencing platform selected by Breining Institute complies with the provisions of the Health Insurance Portability and Accountability Act (HIPAA). However, using any online telehealth format may, by its nature, present a potential risk of disclosure of your personal information. If you do not wish to be exposed to this potential risk, you should not use the online telehealth format to complete your DUI program.

By completing this form, you are voluntarily agreeing to receive and participate in DUI Program services using the online telehealth Internet technology.

Consent to Release of Information

You attest to your understanding that Federal and State laws protect the confidentiality of information relating to Right Direction Services LLC (AKA MyDUIClass.com) participants. By signing below and participating in the Right Direction Services LLC (AKA MyDUIClass.com) program activities using the online telehealth technology, you hereby consent to the disclosure of your personal information, and specifically the disclosure of your name and likeness, to the extent necessary for participation in program services provided via telehealth platforms and specifically the Zoom teleconferencing platform.

Confidentiality / Non-Disclosure Agreement - Other Participant Information.

By signing below I attest to my understanding that information relating to Right Direction Services LLC (AKA MyDUIClass.com) program participants is protected from disclosure by Federal and State laws and regulations. I further understand that these laws and regulations prohibit my disclosing to others any information relating to any Right Direction Services LLC (AKA MyDUIClass.com) program participant. By signing below I indicate my agreement that:

1. I will maintain the confidentiality of all information learned and observations made by me during participation in Right Direction Services LLC (AKA MyDUIClass.com) provided via telehealth platforms and specifically information learned and observations made during the Zoom teleconferencing platform.

2. I will not photograph or record the voice or likeness of any other participant while receiving Right Direction Services LLC (AKA MyDUIClass.com) program services provided via telehealth platforms and specifically during any Zoom teleconference.

3. I will maintain the confidentiality of the teleconference by agreeing not to allow any person other than myself to listen to or observe any Right Direction Services LLC (AKA MyDUIClass.com) teleconference providing program services and specifically any Zoom teleconference.

4. I will not allow any other person to photograph or record the voice or likeness of any participant in any Right Direction Services LLC (AKA MyDUIClass.com) teleconference providing program services and specifically any Zoom teleconference.

Client Acknowledgement

By signing and submitting this Agreement:

• I am choosing to voluntarily participate in the DUI Program Services using the online telehealth Internet technology; and
• I understand that there is no assurance of confidentiality when using the online telehealth technology service due to the nature of the Internet technology.