20-3D

Treatment Program Cardinal Rules

Name: ___________________________________________ Number: _________________________

As a participant in the treatment program at _______________________________ I understand that it

is required that I know and understand these rules. I also understand that I will be expected to abide by
these rules while I am a participant in the program.

1. No drugs or alcohol
2. No violence or threats of violence
3. No sexual acting out
4. No cheating or stealing
5. No gambling
6. No violating confidentiality

By signing below I indicate that I have read or been read these rules. I understand that any violation of
these rules will result in disciplinary action including termination and removal from the program.

___________________________________________ ________________________________
Participant Signature Date

___________________________________________ ________________________________
Counselor Signature RudolphKolderMA Date

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