Consent to Receive Peer Recovery Services

Name*

First NameLast Name

Email*

example@example.com

Date of Birth*

Date

Who is the Certified Peer you are meeting with?

Introduction

&#13;&#10;Thank you for considering participating in Peer Recovery Support Services provided by Amethyst Recovery Solutions. This document contains important information about the nature of the services, potential benefits, risks, and your rights as a participant. Please read it carefully and feel free to ask any questions before proceeding.&#13;&#10;&#13;&#10;Nature of Peer Recovery Support Services:&#13;&#10;&#13;&#10;Peer Recovery Support Services are designed to provide individuals with support, guidance, and resources in their journey towards recovery from substance use disorders. These services involve interactions with trained peers who have personal experience with recovery and can offer empathy, understanding, and encouragement. Peer support may include one-on-one meetings, group sessions, phone calls, and other forms of communication as deemed appropriate.&#13;&#10;&#13;&#10;Potential Benefits:&#13;&#10;&#13;&#10;-Access to a supportive community of individuals who understand your experiences.&#13;&#10;-Encouragement, motivation, and inspiration from peers who have successfully navigated recovery.&#13;&#10;-Practical advice, coping strategies, and resources to help you overcome challenges.&#13;&#10;-Increased feelings of hope, self-worth, and empowerment.&#13;&#10;-Opportunities for personal growth and development.&#13;&#10;&#13;&#10;Risks:&#13;&#10;&#13;&#10;Confidentiality: While every effort will be made to maintain confidentiality, there may be limits to privacy in certain circumstances, such as mandated reporting of harm to self or others.&#13;&#10;&#13;&#10;Emotional Triggers: Participating in peer support sessions may evoke strong emotions or trigger memories related to past experiences with substance use or trauma.&#13;&#10;&#13;&#10;Dependency: While peer support can be highly beneficial, it is important to maintain a balance and not overly rely on others for your recovery journey.&#13;&#10;&#13;&#10;Voluntary Participation:&#13;&#10;&#13;&#10;Participation in Peer Recovery Support Services is entirely voluntary. You have the right to decline any service or withdraw from the program at any time without penalty. Your decision to participate or not will not affect your access to other services or treatment options.&#13;&#10;&#13;&#10;Confidentiality:&#13;&#10;&#13;&#10;Your privacy is of utmost importance. Information shared during peer support sessions will be kept confidential unless disclosure is required by law or deemed necessary to prevent harm to yourself or others. By signing this form, you acknowledge your understanding of and consent to the limits of confidentiality.

I, First Name* Last Name* , acknowledge that by signing below, I confirm my voluntary participation in Peer Recovery Services provided by Amethyst Recovery Solutions. I understand the nature of these services, the potential benefits, and the limitations involved. I agree to abide by the terms and conditions outlined in the Informed Consent Form for Peer Recovery Support Services.

By providing a digital signature, you acknowledge and agree that: You are the authorized individual signing this document electronically. Your digital signature carries the same legal validity and significance as a handwritten signature. You understand and accept the terms outlined in the document. You consent to the electronic transmission and storage of this document and any associated information. Your digital signature serves as confirmation of your acceptance and agreement to the terms specified herein.*

Date Signed*

Date

Consent to Receive Peer Recovery Support Services