This is an agreement between ___________________(the patient) and _______________(the therapist) to help the patient maintain abstinence from cocaine. By this agreement, I direct my counselor to establish a schedule for collecting urine specimens from me for 24 weeks. I will provide urine samples three times each week on a Monday, Wednesday, and Friday during the first 12 weeks of treatment. During the second 12 weeks of treatment (weeks 13-24), urine samples will be collected two times each week on a Monday and Thursday schedule. A clinical staff member of my same gender will observe the urination. Half of each urine sample will be submitted for immediate analysis and half will be saved at the treatment agency. Samples will be assayed for a variety of drugs of abuse, including cocaine, amphetamine, opioid drugs, marijuana, and sedatives.
Each specimen collection requires 3.0 ounces of urine. If the quantity is insufficient for analysis, that will be considered a failure to provide a scheduled sample.
If I travel out of town because of an emergency, I will inform my counselor in advance of leaving. My counselor is authorized to verify such absences with ______________________. I If I require hospitalization, my counselor will arrange to collect urine in the hospital. If I am sick and do not require hospitalization, I will still arrange to produce scheduled urine specimens. If I have difficulty with transportation, or inclement weather makes it difficult to travel, I will work out (with the assistance of the clinical staff) a way to get to the treatment agency. On certain major holidays, the agency will be closed. My counselor and I will mutually agree to altered urine schedules on those occasions.
If, for appropriate medical reasons, a prescription is written for a medication that is sometimes abused, I will supply my counselor with copies of that prescription. The appearance of that drug in the urine will not be counted as a relapse to drug use. I hereby direct my counselor to communicate by mail or telephone with the prescribing physician or dentist when my counselor deems that action to be appropriate.
Cocaine-Free Urines: For each cocaine-negative urine sample collected during weeks 1-12 of treatment, points will be earned. Points are worth the monetary equivalent of $0.25, although they are not exchanged directly for cash. A voucher stating the earned point value will be presented to me following the collection of a cocaine-negative sample. This voucher will specify the number of points I earned for that day, as well as the cumulative points earned to date and their monetary equivalent.
During the first 12 weeks of treatment, the first cocaine-free urine sample will earn 10 points. Each consecutive cocaine-free sample collected thereafter will earn another 5 points above the amount earned before. For example, if 10 points are received on Wednesday for a cocaine-free urine sample, Friday's cocaine-free sample will earn 15 points, Monday's will earn 20, and so on. As an added incentive to remain abstinent from cocaine, a $10 bonus will be earned for each week of three consecutive cocaine-negative urine samples collected at the agency. Assuming there are no cocaine-positive urine samples collected, the monetary equivalent of $ 997.50 can be earned during the first 12 weeks of treatment.
Since a major emphasis in the program is on lifestyle changes, primarily increasing activities that effectively compete with drug use, the money earned on this incentive system must be used toward social or recreational goods and activities agreed upon by myself and my counselor. A list of acceptable uses of vouchers has been developed for this purpose and will be given to me. During the second 12 weeks of treatment, the incentive program will be changed. Rather than earning vouchers for cocaine-negative samples, I will be earning lottery tickets for clean samples.
For the entire 24 weeks of treatment, immediately after the urinalysis test results indicate that the urine sample is cocaine-negative, the vouchers (weeks 1-12) or lottery tickets (weeks 13-24) will be delivered. Following the presentation of each voucher, I will be asked if I would like to purchase any goods or services. Vouchers may be used at any time during the program. Earned vouchers cannot be taken away from me under any circumstance.
Cocaine-Positive Urines: All urine samples will be screened for drug use. A record will be kept of all drugs screened positive, although this contract will be in effect for cocaine only. For each cocaine-positive urine sample collected, I will not receive a voucher. In addition, the voucher earned for the next cocaine-free urine sample will be reset to 10. To reset the voucher value to where it was prior to the cocaine use, I must provide five cocaine-free samples in a row. The fifth clean sample will then earn me the same monetary equivalent as that earned for the sample preceding the cocaine-positive one, and the system outlined above will continue to be in effect (i.e., each clean sample will earn 5 points more than the previous one).
Failure to Provide a Urine Sample: Failure to provide a urine sample on the designated date (without prior approval of my counselor) will be treated as a cocaine-positive sample, and the procedures noted above will be in effect. Although the clinic may attempt to obtain the sample by coming to my home (with my permission), cocaine-negative urine samples collected in this manner will not earn voucher points, nor will they reset my voucher value to 10. In effect, cocaine-negative samples collected outside the treatment program (except in the case of hospitalization) are neutral. If a sample is obtained from me outside of the program, and the sample is cocaine-positive, it will be treated in the manner outlined above for cocaine-positive urine samples.
My signature below acknowledges that I agree to the urinalysis monitoring system outlined above. This system has been carefully explained to me, and I understand the outcome of providing both cocaine-negative and cocaine-positive urine samples while I am a patient at the clinic.
Patient: ________________________
Therapist: ______________________ |
