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Consent for Services

Voluntary consent to participate in Kura Solution recovery housing and support services.

Kura Solution

Appendix D — Consent for Services

Voluntary consent to participate in Kura Solution recovery housing and support services.

I voluntarily consent to participate in recovery housing, case management, peer recovery support, and life skills services provided by Kura Solution.

I understand:

Participation is voluntary
I may withdraw consent at any time
Services are recovery-oriented and not clinical treatment unless specified

Resident Name *

Signatures

Resident Signature *

Sign here

Use mouse, trackpad, or finger to sign.

Resident Printed Name *

Date *

Staff Signature *

Sign here

Use mouse, trackpad, or finger to sign.

Staff Printed Name *

Date *

Electronic Signature ConsentI agree that the signature(s) I have provided above are my legal electronic signatures, with the same effect as a handwritten signature, under the federal E-SIGN Act (15 U.S.C. § 7001 et seq.) and applicable state law (UETA). I authorize Kura Solution to maintain this signed form as a legal record. I have had the opportunity to read and understand this form and my signature(s) are made knowingly and voluntarily.

A signed PDF copy will download to your device after submission. Records protected under 42 CFR Part 2 & HIPAA.