Medication Use Survey

CONSENT TO FOLLOW-UP AND CONSENT TO RELEASE

Sundown M Ranch conducts program evaluation and follow-up studies on all our treatment programs. Sundown M Ranch utilizes an “Web” based program evaluation method. We request that you read the information contained in this release and sign and date the form where indicated. The release of information is for Sundown M Ranch (project evaluation). Mark Loes, Director of Operations at Sundown M Ranch, oversees the overall project management. Any questions or comments can be sent to: Sundown M Ranch, PO Box 217, Selah, WA 98942, or 1-800-326-7444.

PURPOSE AND BENEFITS:

The purpose of this study is to determine the accessibility, effectiveness, efficiency, and satisfaction of the treatment that you received from Sundown M Ranch. The information will help us to evaluate treatment results and will help to ensure quality improvement in the future. The information obtained from you will be grouped with information from others and used for evaluating treatment effectiveness and improving treatment quality. You may refuse to answer any questions or withdraw from the study at any time without affecting your treatment or aftercare.

PROCEDURES:

If you consent, your involvement in the study will consist of participating in one survey at enrollment and one at discharge. You will be requested to complete confidential follow-up surveys at 30 days, 60 days, 90 days, 6 months, and 12 months from the time you complete treatment. The confidential follow-up surveys will be conducted by completing the survey that will be emailed to you. The surveys will include questions about your employment; health; wellness; key support relationships; participation in aftercare and self-help activities; alcohol and drug use; and, satisfaction with the services you received at Sundown M Ranch. Your name will not be kept with the data and you will not be identified in any of the research reports. A unique number is connected to the data and no names or identifiable information is used. All information is confidential.

OTHER INFORMATION:

Participation in this study is entirely voluntary. We feel there are no unforeseeable risks to you if you to enter into this program evaluation. If you decide not to take part in the research or decide to drop out at any time, your treatment will not be affected in any way. If you withdraw consent, no further study contact will be made.

THANK YOU FOR YOUR PARTICIPATION

Consent

I have read and agree with the above statement

Please Enter your Email Address, Program and Medical Record Number

Thank you for your taking the time to take this survey

Email*

Program*

Medical Record Number*

Consent that the above Medical Record is valid*

I agree to the privacy policy.

I agree that I am the owner of the above Medical Record Number.

To what extent would you agree with the following statements?

1. I was satisfied with the medication(s) prescribed for me.

2. The medication(s) prescribed is/was based on my needs and preferences.

3. The medication prescribed is/was effective.

4. Side effects and contraindications of the prescribed medication(s) was addressed

5. Medication interactions were evaluated by SMR staff

Medication Use Survey

Medication Use Survey

Consent

To what extent would you agree with the following statements?

DISCRETION AND CONFIDENTIALITY

PHONE

ADDRESS