SSPR Recovery Support Services: Enrollment Form

SSPR Recovery Support Services

Enrollment Form
Provider making a referralIndividual requesting services

SSPR Recovery Support Services

Enrollment Form
South Shore Peer Recovery - Individual Peer Recovery Support Services Agreement
South Shore Peer Recovery - Individual Peer Recovery Support Services Agreement

Please review this document and acknowledge your willingness to engage in the SSPR Individual Peer Recovery Support Services program (Individual RSS) and work with a SSPR Peer Recovery Support Specialist.

By entering this relationship, you acknowledge that you want to make progress and change in your recovery journey. Because progress and change happen at different rates, the PRSS and participant commit to working with each other for an initial three month period although additional sessions are encouraged. This program consists of regularly scheduled weekly, bi-weekly, or monthly engagements. After six months of engagement, sessions will step down in frequency moving from weekly towards monthly. Exceptions may apply.

Here is what you can expect from me, your SSPR Peer Recovery Support Specialist:

1.    I will support you and help you to establish a plan for life in recovery.

2.    I will help you to connect with people, services, and communities that can help you succeed in and enjoy your recovery.

3.    The centerpiece of our relationship is a constantly developing Recovery Plan. Our conversations will focus on goal setting, problem-solving, and celebrating all positive changes. As your recovery is unique to you and belongs to you, your recovery planning will be unique and driven by you.

4.    I will keep my relationship with you confidential, but I will acknowledge your participation in this program if you request that I do so in writing.

5.    I will not provide an evaluation of anyone’s recovery or report on anyone’s use of substances. We only acknowledge the period of time someone has participated in this program, the regularity of their engagements, and acknowledge a person’s commitment to working on a personal recovery process.

6.    Depending on your individual circumstances and wishes, I may provide general information about your recovery progress and / or challenges to your service providers, and / or caretakers.

7.    I am legally and ethically obligated to report any participant’s disclosure of personal involvement with child or elder abuse/neglect, threatened self-harm, or harm to others.

8.    I do not provide clinical assessments, recommend any particular level or type of care, provide clinical treatment services, maintain clinical records, or dispense medications.

Here is what I expect from you:

1.    Your recovery is your responsibility. Any decisions you make after considering your options in the recovery coaching process are your decisions and your responsibility.

2.    You understand and agree that you will not seek to hold me or SSPR and any of SSPR’s agents legally responsible for your decisions or actions.

3.    You will make every effort to ensure you are at your peak, mental, physical, and emotional state for each session, understanding that you cannot be under the influence while at the Recovery Center.

4.    Please keep appointments we make together and be on time. If you are unable to keep your scheduled appointment, please contact me as soon as possible.

5.    You can contact the team member who signs this packet with any questions or concerns you have about your experience with the program or if you feel you might benefit from having a different peer specialist.

Together, we will explore what you can do to meet your recovery-oriented goals. We will support you in taking action and making your recovery successful.
Declaration of Confidentiality
As an individual engaging with peer recovery support services, you have the right to confidentiality. This means that peer provider organization staff do not have the right to share any information about you verbally or in writing with anyone outside the organization and your support team without your written consent. However, in some cases, the organization must bring outside individuals into the relationship, without your consent, to ensure your safety and well-being and that of others.

Everything you say, do, express is confidential EXCEPT:

-Intent or plan(s) to harm yourself
-Intent or plan(s) to harm another person
-Knowledge or case(s) of a child or elderly person being abused/harmed/neglected
-In an emergency situation regarding your physical safety
-If a warrant signed by a judge and served by law enforcement demands release.

Also, please note that information about you may be shared with co-workers and supervisors at the organization only to obtain professional guidance and suggestions regarding care planning and referrals. Discretion will be used in these cases.

The organization collects personal information and take considerable measures to protect any information collected, stored, transported, and shared. We may be required by your payor entity to collect personal information and report on your progress. Other personal information that we collect is to provide you with appropriate and quality services.
Enrollment
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Address (zip code required)*

Street Address

Street Address Line 2

CityState

Zip Code
Lives at this address?
County
Pronouns
Gender Identity*
Alaskan NativeAmerican IndianAsianBlackNative Hawaiian or Other Pacific IslanderWhiteOther Race Not ListedPrefer not to answer or unknown
Ethnicity*
Have you ever engaged in peer services at SSPR before?*
Intake Source
Intake Source Name
How frequently would you like to meet with your peer support specialist?*
How would you like to engage with your peer (select the most preferred way)?*
Are there things you think your peer should know so they're able to best help you? (for example: living situation, employment status, education, relationship status, other health diagnosis, etc)
By signing this form:
- I understand that I can change the frequency, duration, and engagement channel at any time in the future.
- I understand that I can withdraw the consent to receive services at any time.
- I accept that I authorize peer specialist professionals and the peer provider organization to provide me recovery support services and to have my personel health information in Recovery Link.
- I accept that I authorize the provider organization and provider organization staff to contact me via e-mail, SMS, and/or phone for the purposes of providing recovery support services
I understand the above statements and agree to provide my consent by digitally submitting below.
*If you are an individual enrolling yourself, the process is complete. Please hit SUBMIT button below. Thank you.

Referrer's name (Not participant)

First NameLast Name
Referrer's email (Not participant)
example@example.com
What is your relationship to participant? (doctor, case manager, etc.)
Participant Name

First NameLast Name
Participant Date of Birth

MonthDayYear
Date
Participant Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Participant Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Participant Email
example@example.com
Participant Gender Identity
Alaskan NativeAsianBlackNative Hawaiin or Other Pacific IslanderWhiteOther Race Not ListedPrefer not to answer or unknown
Participant Ethnicity
Is there anything you would like us to know? (Participant requests to work with female peer support specialist, prioritize employment, is pregnant, needs housing etc.)
Should be Empty:

SSPR Recovery Support Services

SSPR Recovery Support Services

South Shore Peer Recovery - Individual Peer Recovery Support Services Agreement

Declaration of Confidentiality

Enrollment