Multi Concept Recovery-Parent Research Permission

I agree that my child (or the child from whom I am the legal guardian, who shall be hereinafter referred to as “my child”) may participate in progress monitoring research designed to improve the effectiveness of the treatment he or she receives while enrolled at Multi Concept Recovery (“Multi Concepts”).   This monitoring will include information about potential mental health conditions, current and previous drug and alcohol use, and satisfaction with treatment.   I understand that this research will be conducted by Vista Research Group, Inc. (“Vista”) and that all information my child provides while in treatment will be immediately shared with the clinician(s) and/or the leadership of Multi Concepts so that it can be used to improve my child’s treatment.

I also agree that Vista can contact my child periodically during the first 13 months after he or she leaves Multi Concepts to determine how well he or she is doing.  Information he or she provides after treatment will be kept strictly confidential and will only be provided to the leadership of Multi Concepts after it has been de-identified and combined with that of many other patients.  The only exception to this would be if my child specifically requests that Vista notify Multi Concepts that he or she would like to be contacted by them to potentially consider going back into treatment.  This post-treatment outcomes research is designed to help Multi Concepts improve the treatment it provides to future clients.  As my child is not benefitting directly from this portion of the research, he or she will receive a small stipend in appreciation for his or her time.

I also agree that Multi Concepts may share with Vista my child’s name, medical record number, birthdate, gender, phone number(s), email address, the name and type of his or her health plan, the name(s) of his or her primary clinicians, and the dates and reasons why he or she is admitted, transferred and discharged from Multi Concepts’s program(s).

I understand that health information that may be used to identify my child is protected under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and 45 C.F.R. Parts 160 and 164.  The confidentiality of my child’s health information may also be protected under 42 C.F.R. Part 2.  I understand that my child’s personally-identifiable health information and/or substance use disorder treatment records cannot be disclosed without his or her written consent unless otherwise provided for by these federal regulations.  In addition, except where otherwise permitted under state law, my written authorization is required prior to disclosure of such records.

I understand that this consent expires 13 months after my child has left Multi Concepts, and that my child has the right to revoke this authorization at any time by emailing  Finally, I understand that my child’s enrollment at Multi Concepts is not contingent upon his or her involvement in this research.

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