UA Consent and Limited Authorization to Release UA Results

I consent to baseline, random, and return-from-overnight urinalysis (“UA”) testing required by Kate’s House Foundation as a condition of entry to, and continued residence in, housing.

I authorize Kate’s House Foundation to use and disclose only the following UA information: the date of the UA, whether the UA was completed, refused, tampered with, inconclusive, negative, or positive, and the substances indicated by the UA, if any.

This limited authorization applies only to:

• Kate’s House Foundation staff and designated representatives with a legitimate need to know for housing intake, supervision, safety, rule enforcement, case coordination, or program operations, including house managers, house leads, peer support staff, and leadership team members;
• Drug Court staff involved in my case;
• My counselor, treatment provider, case manager, or program staff involved in my care or supervision; and
• Department of Corrections (DOC) staff or my assigned DOC officer.

This authorization does not permit Kate’s House Foundation to request, use, or disclose my general medical records, mental health records, hospital records, diagnosis, treatment notes, therapy records, medication history, or any other health information beyond the limited UA information described above.

I understand that this authorization is voluntary. I may revoke it at any time by providing written notice to Kate’s House Foundation, but any disclosure made before revocation will remain valid. Unless earlier revoked, this authorization expires one (1) year from the date of my signature or upon my discharge from Kate’s House Foundation housing, whichever occurs first.

Privacy & Confidentiality Acknowledgement:
Kate’s House Foundation is committed to protecting the privacy, confidentiality, and security of information submitted through this website. Resident and program information is handled separately under applicable confidentiality rules, and we do not confirm or disclose an individual’s housing, services, or program participation to third parties without a specific, written authorization signed by the resident, unless required by law.

Read our Privacy & Confidentiality Policy

House Rules and Medication Policy Acknowledgement:
I acknowledge that I have received, read, and understand the house rules and program requirements of Kate’s House Foundation. I understand that compliance with all house rules, including but not limited to curfews, conduct, substance use policies, visitor restrictions, chores, and safety protocols, is a condition of admission and continued residence.

I understand that if I am taking any lawfully prescribed medication, I am required to disclose it during intake as applicable and comply with all program policies regarding medication review, approval, storage, and use within the home. I understand that certain medications may affect UA results and must be reviewed by staff.

I understand that failure to comply with house rules or program requirements, including medication-related policies, may result in corrective action, up to and including immediate discharge from housing and notification to referring or supervising agencies, as applicable.

Electronic Signature Acknowledgement

By entering my initials above, signing below, and submitting this form, I acknowledge that I have read and understand the required notices, acknowledgements, house rules, and program requirements of Kate’s House Foundation.

I certify that all information I have provided is true, complete, and accurate to the best of my knowledge, and that all required acknowledgements have been completed.

I understand and agree that my electronic signature is intended to have the same force and effect as my handwritten signature and may be relied upon by Kate’s House Foundation, its staff, and referring or supervising agencies, as applicable.