Authorize:
To disclose: Ashlie Nelson, LPC 3930 North College Ave., Bethany, OK 73008

For the purpose of: The purpose of and need for the disclosure is to inform the criminal justice
agency(s) listed above of my attendance in the assessment process. The extent of information
to be disclosed is all medical, psychological and drug or alcohol testing records and reports or
similar information maintained by you to my attorney, treatment center or their agents or
employees or other authorized personnel. This includes but is not limited to all reports,
memoranda, employee notes or summaries. This information is to be held confidential by all
parties receiving same and no further authorization for release of my records to any other
person or party is intended by this release. Xerox or email copies of this authorization are to be
treated with the same force and effect as an original. When a valid court order is issued for
records the clinician is bound by law to comply with such request.
I understand that my alcohol and/or drug abuse treatment records are protected under Federal
regulations 42 C.F.R., Part 2 - Confidentiality of Alcohol and Drug Abuse Patient Records and
cannot be disclosed without my written consent. I may revoke this consent orally or in writing at
any time. I understand that the revocation will not be effective retroactively for information
disclosures that have already occurred. If not previously revoked, this consent will terminate
upon:
7 YEARS FROM THE DATE OF COMPLETION OF YOUR RECOMMENDATIONS
**Treatment and services are not contingent upon or influenced by the consumers decision to
permit the release of information. **
The Following Information: Assessment scores, report and any information deemed necessary
by Ashlie Nelson for me to acquire the services needed to help alleviate any future occurrence
of such situation.

An Alcohol and Drug assessment consist of a face-to-face clinical interview, at least three (3) testing
instruments, and a closing summary in which the scoring of the test and the conclusions and
interpretations are presented to you so that you will understand the results of your assessment.
You have the right to understand the results of your testing and assessment, and how it will affect you.
These assessment results will determine a level of education, treatment or both, as part of a set of
recommendations for reinstatement of your driving privileges.
This testing and assessment process is not a pass or fail process. There is no right or wrong answers, but
to be accurately assessed, you need to be open and truthful in your responses. Your information is
protected by Federal and State Law, which cannot be released without your written permission, and with
specific exceptions, may not be used to criminally prosecute you (child abuse, elder abuse, medical
emergency, and threats of harm to yourself or another person). The process is intended to give you the
right combination of services to help you to avoid similar troubles in the future.
This assessment process will take some time: about two (2) hours. If you have problems with reading or
comprehension, it may take longer. We will assist you as much as we can.
FEES:
DUI/ADSAC Assessment $160
Addition Assessment-Various Fees *NDPS ADSAC $250
Additional Forms or letters $50 per page
Additional Services requiring my time by you, or 3 rd party $200 per hour
Court Appearance $400 per hour (this includes drive time and waiting time for hearing even if I am not
called to testify)
If you are under the influence of alcohol or other drugs at the time of your appointment for testing and
assessment, you will be asked to make another appointment.
You will be given an opportunity to sign a release for results to be reported to a third party, if needed. You
should be aware of exactly what information will be released and to whom.
Your assessment testing and assessment documentation will be kept in this office for Seven (7) years. If
during that time you need another release of information, contact our office for help.
I understand the cost of assessment, the purpose of this
assessment, and the time involved. I understand that my truthfulness and honesty will produce the most
accurate results. I understand that the results of the assessment will determine other requirements for
reinstatement of my driving privileges. I give my consent for Mrs. Ashlie Nelson to perform my
assessment.

Oklahoma Department of Mental Health and Substance Abuse Services
CONSUMER RIGHTS

Each consumer has the right to be treated with respect and dignity.

Furthermore:
Each consumer shall retain all rights, benefits, and privileges guaranteed by law except those lost through due process of law.
Each consumer has the right to receive services suited to his or her condition in a safe, sanitary and humane treatment environment regardless of race, religion, gender, ethnicity, age, degree of disability, handicapping condition or sexual orientation.
No consumer shall be neglected or sexually, physically, verbally, or otherwise abused.
Each consumer shall be provided with prompt, competent, and appropriate treatment and an individualized treatment plan. A consumer shall participate in his or her treatment programs and may consent or refuse consent to the proposed treatment. The right to consent or refuse consent may be abridged for those consumers adjudged incompetent by a court of competent jurisdiction and in emergency situations as defined by law.
Additionally, each consumer shall have the right to:

• Allow other individuals of the consumer’s choice participate in the consumer’s treatment and with the consumer’s consent;

• To be free from unnecessary, inappropriate, or excessive treatment;

• To participate in consumer’s own treatment planning;

• To receive treatment for co-occurring disorders, if present;

• To not be subject to unnecessary, inappropriate, or unsafe termination from treatment; and

• To not be discharged for displaying symptoms of the consumer’s disorder.

Every consumer’s record shall be treated in a confidential manner.
No consumer shall be required to participate in any research project or medical experiment without his or her informed consent as defined by law. Refusal to participate shall not affect the services available to the consumer.

A consumer shall have the right to assert grievances with respect to an alleged infringement on his or her rights.

Each consumer has the right to request the opinion of an outside medical or psychiatric consultant at his or her own expense or a right to an internal consultation upon request at no expense.

No consumer shall be retaliated against or subjected to any adverse change of conditions or treatment because the consumer asserted his or her rights.

ODMHSAS: Office of Consumer Advocacy
E-Mail: AdvocacyDivision@odmhsas.org
Local: (405) 521-4256
Toll Free: (866) 699-6605
Reach Out Hotline: (800) 522-9054

If asked, a client will be given a complete copy of the Client/Consumer Rights.

Grievance Policy

This office is fully committed to conducting all activities in strict conformance with the codes of ethics for all served. We will comply with all legal and ethical responsibilities to be non-discriminatory in promotional activities, program content and in the treatment of program participants. The monitoring and assessment of compliance with these standards will be the responsibility of the operator, Ashlie Nelson.

While we go to great lengths to assure fair treatment for all participants and attempts to anticipate problems, there will be occasional issues which come to our attention which require intervention and/or action on our behalf. This procedural description serves as a guideline for handling such grievances.

1. When a consumer files a grievance (either orally or in writing to ashlie@timetotalk.co) and expects action on the complaint, we will respond in a reasonable, ethical and timely manner (30 days). For all grievances, the owner/Ashlie Nelson will review the grievance and consult with ODMHSAS/ADSAC Division. The following actions may be taken.

2. A consumer has the right to make a complaint to Ashlie Nelson or ODMHSAS Consumer Advocacy Division. A consumer shall have unimpeded and confidential access to either the facility directly or ODMHSAS.

3. The designated local advocate, Ashlie Nelson, shall work with staff and contractors to ensure the needs of consumers are met at the lowest level possible and that consumer rights are enforced and not violated.

4. A written notification to the consumer of the grievance will be provided within 60 days and the consumer has the right to an appeal within an additional 5 days.

5. An annual review of the grievance policy including ways to improve performance-based outcomes will be conducted.

6. All grievances will be retained for a period of no less than seven years in accordance with our record retention policy. Complaints and grievances are reviewed as a group on at least an annual basis to identify possible patterns or systemic concerns.

* In no event will the financial responsibility for resolving a grievance or complaint exceed the purchase price of the item in which the consumer was enrolled, and which are directly related to the grievance.

* In marketing materials, we may summarize this policy as follows, or via substantively equivalent wording:
“We will respond to grievances in a reasonable, ethical and timely manner. Grievances may be submitted by consumers to ashlie@timetotalk.co. Complete Grievance procedures can be requested by email.”

Email: ashlie@timetotalk.co
Telephone number: 405-314-2920
Address:  3930 N. College, Bethany, OK 73008