TE_3-_Attch_4a._DA_Form_5018_instructions_v11Sep2018.pdf

Version 11 September 2018

SECTION A:

1. Name field reflects client’s first and last name, but will be accepted with the middle initial or full middle name.

2. Date field needs to include the last two digits of the current year.

3. The remaining fields are prefilled on the most current file located on the CDE sharepoint website. If your form says anything other than what is reflected here, you have the wrong form!

SECTION B:

1. Option 1 checked.

2. *Signature of client field can either be digital or printed.

3. Date field MUST MATCH the date field of the witness.

4. Name of witness can either be typed or printed.

5. Signature of witness can either be digital or printed.

6. Date field of witness MUST MATCH the date field of the client.

*If the applicant is a minor, a parent or guardian must sign in the “signature of client” field.

SECTION C:

1. Leave Section C blank.

DA Form 5018-R ( Same as “Appendix M CSSC Template DA-5018-R fillable March 2018”) Instructions

The Alcohol and Drug Abuse Prevention and Control Program (ADAPCP) Client’s Consent Statement for Release of Treatment Information (DA Form 5018-R) is completed by the applicant.

By signing, the applicant agrees that ADAPCP can release information regarding their treatment.

Use the most up to date file located on the CDE sharepoint website, named “DA Form 5018_R fillable March 2018” or the CSSC sharepoint file named “Appendix M-CSSC Template DA Form 5018_R fillable March 2018.”