Controlled Substance & Alcohol Session: Agency Commitment Form

CSA Agency Commitment Form

CSA Agency Commitment Form

Form must be completed in order for attendance to be verified with referring agency.

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:

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.

/s/
please sign with your full name