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.
Are you living with HIV/AIDS?*

YesNo
Name*

First NameLast Name
Preferred Pronouns:*

She/HerHe/HimThey/ThemOther
Date of Birth*

MonthDayYear
Date
Are you enrolled in the North Dakota Ryan White Program?*

YesNo
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Country of Birth?*
Email *
example@example.com
May we send emails to this address regarding Canopy's Ryan White/HIV services?*

YesNo
Phone Number*
Please enter a valid phone number.
Can we leave a detailed voicemail at this number regarding Canopy's Ryan White/HIV services?*

YesNo
Can we send a text message to this number?*

YesNo
Preferred method of communication?*

EmailPhone callText messageVideo callIn-person meeting
Which service are you interested in? (select all that apply)

In-Person Support GroupsOnline Support GroupsOnline Recovery Support Groups (for those interested in pursuing sobriety, recovery and/or harm reduction.One-to-one Peer Support (for those interested in being paired with a Peer Support Navigator who has similar lived experiences).
Are there any area of support you are specifically interested in? (select all that apply)

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, please inform our clinic staff.

Release of Information & Consent to Receive Services

By submitting this registration form you consent to receiving services from Canopy Peer Navigation Program and to the release of information among members of the Canopy Peer Navigation Program — including any clinical supervisor, the North Dakota Ryan White Program (for North Dakota Ryan White participants), and/or Minnesota Ryan White program or their affiliates (for Minnesota Ryan White participants), for the purposes of case management and coordination of care. If you are a Canopy or Ryan White staff member submitting this form on behalf of the client, you certify that you have read The Release of Information and Consent to Receive Services to the client and received consent from the client to submit the completed form
Name of individual submitting form:*

First NameLast Name
Signature*

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Date*

MonthDayYear
Date
Please verify that you are human*
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