Unity Recovery - Participant Enrollment Forms

Peer Services Agreement

Please review this document and acknowledge your willingness to engage in the receipt of peer support services from a peer support specialist at Unity Recovery (the provider organization).

Here is what you can expect from your peer specialist:

Your peer will support you and help you to establish a plan for life in recovery and/or re-entry.
Your peer will help you to connect with people, services, institutions, and communities that can help you succeed in and enjoy your recovery and/or re-entry.
The centerpiece of the relationship is a constantly developing Recovery Plan and/or Re-entry Plan. Conversations will focus on goal setting, problem-solving, and celebrating all positive changes. As your recovery and/or re-entry is unique to you and belongs to you, your recovery planning will be unique and driven by you.
Your peer will keep their relationship with you confidential, but will acknowledge your participation in this program if you request that I do so in writing.
Depending on your individual circumstances and wishes, your peer may provide general information about your progress and / or challenges to your service payors, service providers, and / or caretakers.
Your peer is legally and ethically obligated to report any disclosure of personal involvement with child or elder abuse/neglect, threatened self-harm, or harm to others.
Your peer does 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 is expected from you:

Your recovery and/or re-entry is your responsibility. Any decisions you make after considering your options in the peer services engagement process are your decisions and your responsibility.
You understand and agree that you will not seek to hold your peer or the peer provider organization and any of the peer provider organizations’ agents legally responsible for your decisions or actions.
Keep appointments made and be on time to each appointment. If you are unable to keep your scheduled appointment, please contact your peer as soon as possible.
You can contact the peer provider organization supervisor 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, you and your peer specialist will explore what you can do to meet your recovery and/or re-entry oriented goals. We will support you in taking action and making your recovery and/or re-entry successful.

Declaration of Confidentiality

As an individual engaging with peer 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.

When you enroll in services, you will be asked to sign a copy of this consent declaration.

Your Name*

First NameLast Name

Pronouns*

Your Date of Birth*

Date

Address (only zip code is required, the remainder is optional)*

Street Address

Street Address Line 2

CityState

Zip Code

Primary Phone Number*

Area CodePhone Number

Secondary Phone Number

Area CodePhone Number

Your Email*

Confirmation Emailexample@example.com

Your Gender Identity*

Your Race (Select all that apply)*

Your Ethnicity*

Have you ever engaged with peer services at Unity Recovery before?*

How would you like to engage with your peer (select the most preferred way)?*

What type of peer support services are desired?

SUD Peer SupportMH Peer SupportRe-entry Peer SupportGeneral Peer Support

Anything else you would like us to know? (e.g., I would like to work with a female identifying peer, I am a parent or pregnant mother, I really need help with employment, etc)

By submitting this form,

I understand all the above stated policies of the provider organization.
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 and/or re-entry support services.
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 peer support services.

By checking this box I am acknowledging that I am providing my digital consent to receive services from Unity Recovery and agree to all policies associated with this enrollment form.*

I understand the above statements and agree to provide my consent by digitally submitting below.