Controlled Substance & Alcohol Session: Agency Commitment Form

Below are some strategies to help you lower your risk related to alcohol and controlled substances. These ideas have worked for others. Please check those that you think might be useful to you.

Strategies for risk reduction:

Avoid controlled substances

Alternate alcohol and nonalcoholic drinks

Avoid drinking games

Never leave your drink unattended

Don’t use alcohol with stimulants

Select a member of your group to be the designated driver

Refuse to ride in a vehicle with an intoxicated or high driver

Have an exit plan before attending a party or event

Let a sober person know where you will be

Be prepared to refuse assertively when pressured to use alcohol or a controlled substance

Be aware that individuals under the influence cannot consent to sex

Use the “Buddy System” to watch out for each other and get home safely Use the “Buddy System” to watch out for each other and get home safely

Keep in mind that choosing not to drink/ use is always a legitimate choice

Take helpful action if a friend is ill or passes out / do not be a ‘bystander’

Practice ways to be comfortable in social situations without drinking/ using

Spend more time with friends who do not drink or use controlled substances

Learn about the effects of any drug/ substance you are thinking about taking

Think about the effects of your actions on your future

Think about the effects of your actions on your friends/ family

OtherOther

This portion of this document, including your name, will be available to your referring agency if requested. This document is a commitment or agreement to future behaviors related to alcohol and controlled substances. This document does not reflect any admission or denial of any prior action.

Explain 3 ways you commit to reducing alcohol and controlled-substance related risk for yourself: *

Additionally describe at least two (2) ways you can commit to reducing controlled substance-related risk in your community: (What can you do to reduce risk in your community?) *

Signature *

/s/

please sign with your full name

Date

Controlled Substance & Alcohol Session: Agency Commitment Form

CSA Agency Commitment Form

Below are some strategies to help you lower your risk related to alcohol and controlled substances. These ideas have worked for others. Please check those that you think might be useful to you.

This portion of this document, including your name, will be available to your referring agency if requested. This document is a commitment or agreement to future behaviors related to alcohol and controlled substances. This document does not reflect any admission or denial of any prior action.

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