Probation Agreement

Probation Agreement

This form is only for patients on probation. Please complete if instructed to do so by a program manager.

The patients at Core Health , in the Buprenorphine program will receive a “second chance” to return to his/her treatment program with this probationary warning for a period of thirty days to six months, with an additional probation fee associated with this program. This program was designed for those clients who have failed a routine urine test, failed to meet the group attendance requirement, and failed for illicit prescriptions noted on the NC Controlled Substance Data report.

If during the probation time frame as assigned by the clinical team the client violates the rules again, they will be immediately terminated from the Buprenorphine treatment program at Core Health Addiction Care, PLLC. The patient must maintain a desire for recovery.

The client will continue to participate in bio-chemical analysis testing while in the probationary status for a thirty-day period and remain clear of benzodiazepines and/or other illicit drugs.

The client’s North Carolina Controlled Substance Data report must show prescriptions as prescribed by Core Health with acknowledgement of medications prescribed by his/her Primary Care Physician.

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Probation Reasons & Treatment Plan:

1. Failed to meet group attendance:
a. Prescription modified (discretion of clinical team)

2. Failed UDS with non-prescribed medications (benzo’s, cocaine, methadone, ↑ETOH) a. Prescriptions modified (discretion of clinical team) b. Weekly UDS

3. Failed to meet payment requirements (account kept at Zero $ balance)
a. Prescriptions modified with payment arrangement (discretion of clinical team)

4. This probationary letter is a notification to you as a last chance opportunity, and any
further violations will cause you to be discharged from the program and could cause
you to not be readmitted into the program.

Patients are required to sign this letter for his/her file, explaining probation and the length of the probationary period (discretion of clinical team).

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