| I, _________________________________, agree to take disulfiram at the regularly scheduled time outlined below.
I agree to do this for ______ days. After this time, I agree to talk to my therapist and to discuss whether or not to continue taking disulfiram. I also agree to have the person designated below witness the administration of the disulfiram each time it is scheduled.
I, _________________________________, agree to be present and witness each take-home administration of disulfiram.
Time: __________________
Days: __________________
Where: __________________
In response to _________________________________ taking disulfiram as scheduled, I agree to _________________________________ as a means of reinforcing the taking of disulfiram.
Patient's Signature:
________________________________
Partner's Signature:
________________________________
Therapist's Signature:
________________________________
Date:
________
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