Canopy Peer Navigation Program

Canopy Peer Navigation Program
The Canopy Peer Navigation Program is available to anyone living with HIV/AIDS living in North Dakota and offers two ways to engage:

1. Individual Peer Support: If you chose Individual Peer Support, you will be paired with a Peer Support Navigator with similar lived experiences. Peer Support Navigators are not trained clinicians, rather they are people living with or who have lived experience with HIV/AIDS, have learned to navigate many difficult situations and/or complicated systems, are willing to share their tips, or simply provide a listening ear.

2. Canopy Peer Group Support: The Canopy Peer Navigation Program offers numerous Group Support meetings per month that are led by individuals living with HIV. Support groups are hosted both on-line and in-person throughout North Dakota.

Please fill out the form below to better help us match you with the services in which you are most interested. For the security of all involved, any application for a person who cannot be verified as a person living with HIV/AIDS in North Dakota will be discarded.
YesNo
Name*

First NameLast Name
She/HerHe/HimThey/ThemOther
Date of Birth*

MonthDayYear
Date
YesNo
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Country of Birth?*
Email *
example@example.com
YesNo
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
YesNo
YesNo
EmailPhone callText messageVideo callIn-person meeting
Fargo In-Person Support GroupBismarck In-Person Support GroupOnline Support GroupsOnline Women's Group (for women and those identifying as women/feminine)Online Recovery Support Group (for those interested in pursuing sobriety, recovery and/or harm reduction).
YesNo
I am newly diagnosed with HIVBasic information about HIVRyan White Services and How to ApplyHIV Medical Services & ProvidersSTI Testing and ResourcesLGBTQ+ ResourcesTribal Members, Communities & ServicesForeign Born PersonsDiscussing HIV Status with Family, Partner(s) & OthersHIV Status & Confidentiality (e.g. employment disclosure)Substance Use & Related Resources (e.g. syringe service programs, treatment, sharing experience)Mental Health, Support Groups and Other Community EventsTips for taking Meds, Refills & Pharmacy QuestionsResources for Partners such as HIV PrEP
Consent to Receive Electronic Communications

Canopy Medical Clinic and the Peer Navigation Program may use e-mail and text messages to communicate with clients. We encourage all participants to be thoughtful regarding how they communicate with our clinic and Peer Navigators and take necessary precautions to safeguard their protected health information. By nature, emails and text messages are NOT confidential. This includes communicating with our clinic in public spaces, using work email, etc. Email, text messages, and portal messages should not be used in an emergency. You have the right to decline to receive electronic communications from Canopy Medical Clinic. If you do not want Canopy Medical Clinic to communicate with you via electronic communications, or if you wish to stop receiving electronic communication in the future, please inform our clinic staff. Your consent to receive electronic communication is valid while you are receiving services from Canopy Medical Clinic's RW Support Program.

Release of Information & Consent to Receive Services

By submitting this registration form you consent to receive services from Canopy's Ryan White Program and for the release of your information to other North Dakota Ryan White stakeholders — including any clinical supervisors, the North Dakota Ryan White Program, and/or Minnesota Ryan White program or their affiliates, for the purposes of case management and coordination of care. Your consent for the release of information among Ryan White programs and stakeholders is valid while you are receiving services from Canopy Medical Clinic's RW Support Program.
Name of individual submitting form:*

First NameLast Name
Signature*

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Date*

MonthDayYear
Date
Please verify that you are human*
I have collected and discussed the information above with the named client. The client has been given an opportunity to ask questions and all questions have been answered. The client named has given their verbal consent to receive electronic communication, release information as described above and consents to receive as services described.
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