Substance Use Disorder Program Internal Forms

These forms are for Canvas Health staff internal use only.

Client Intake Orientation & Acknowledgement | rev. 7/2/2024
Client Welcome Letter | rev. 7/2/2024

Program Information

Concerned Persons Program | rev. 7/2/2024
Substance Use Fee Schedule | rev. 7/2/2024

Client Policies

Substance Use Treatment Contract | rev. 7/2/2024
Attendance & Accountability Expectations | rev. 7/2/2024
In-Jail Program | rev.7.2.2024
Use of Cell Phones, Photos of Clients, Risks Associated with Treatment | rev. 6/19/2024

Canvas Health Policies

Notification of DAANES Data Collection | rev. 7/2/2024
Substance Use Treatment Client Bill of Rights | rev. 7/2/2024
Confidentiality – Orientation for Substance Use Treatment Client | undated
Notice of Privacy Practices | undated
Mandated Reporting of Suspected Maltreatment of Vulnerable Adults Policy | rev. 11/7/2023
Mandated Reporting of Suspected Maltreatment to Minors | rev. 11/7/2023
Customer Complaint, Grievance, Appeals, and Nonretaliation Policy | rev. 5/12/2023
Notice of Nondiscrimination, Accessibility & Language Access | rev. 6/18/2024

Brochures & Education

Fetal Alcohol Syndrome Disorder | undated
Fight TB | rev. 4/2018
Hepatitis A Fact Sheet | rev. 7/2020
Hepatitis B Fact Sheet | rev. 6/2016
Hepatitis C Fact Sheet | rev. 4/2020
HIV Training & Resources for Substance Use Disorder Programs | undated
Opioid Education (DHS-6745-ENG 2-24) | undated
Options for Opioid Treatment in Minnesota and Overdose Prevention (DHS-6745-ENG 5-20) | undated
STD Basics | rev. 11/7/2022

Release of Information & Recordings (signed)

MN Adult Abuse Reporting Center | rev. 11/10/2023
Premier Biotech | rev. 11/10/2023
42 CFR General Consent | rev. 12/28/2023
Consent for Recording (Correctional) | rev. 7/19/2019