Prevention TRS

Participant Name*

First Last

Date of Birth*

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Status

I am a current Participant
I am completing this form to become a Participant

Home Address*

If current address does not exist please use NA

Street Address Address Line 2 City State ZIP Code

County of Residence*

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My Program is:*

TRS - PIK

Race*

White
Hispanic, Latino, or Spanish Origin
Black or African American
Middle Eastern or North African
American Indian or Alaska Native –
Asian –Native Hawaiian or Other Pacific Islander
More than one race
Other

Ethnicity

Hispanic
Not Hispanic
Unknown
Other

Gender*

Male
Female
Other
Nonbinary

Primary Phone*

Participant Email

CONSENT AND TELEPHONE RECOVERY SUPPORT INFORMATION

The purpose of the disclosure authorized in this consent is to receive recovery support. I understand that my alcohol and/or drug treatment records are protected under the Federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 C.F.R. Pts. 160 &164 and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent at any time. I understand and agree to the following: 1. I grant permission for a volunteer to call me at the above phone number, email, and/or address to support me in my recovery. 2. Each time the volunteer calls, he/she will be asking me how my recovery is progressing and if I am in need of additional support (i.e., meetings in area, recovery community centers, safe/sober housing, social events, other resources). 3. At the time of the call, if I am in need of a referral to a treatment program or detox unit, I will be assisted in finding a program, if I so desire. 4. If at any time I decide not to take part in this program, I will contact the center or tell the volunteer when he/she calls.

Consent*

I agree to the above.

Best Days to Call:*

Select All
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
Saturdays
Sundays

Best Time to Call:*

Morning
Afternoon
Evening
Anytime

TRS Frequency*

Weekly
Monthly
Quarterly

TRS X per Frequency*

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Forms to be Completed

New Participants must complete a consent form. The other forms are optional.

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Forms to be Completed*

Select All
Informed Consent
Release of Information
Emergency Contact

At least one form must be completed. New participants should at a minimum complete the Informed Consent.

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Person Completing Form:*

Participant (adult)
Not the Adult Participant
Participant (minor)
Parent or Guardian of minor

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INFORMED CONSENT, PRIVACY AUTHORIZATION, AND PARTICIPANT AGREEMENT

This document is meant to explain Prevention Links program policies, State and Federal laws, and your rights. It also serves as an agreement to participate voluntarily in Prevention Links Recovery Support Division programs. If you have other questions or concerns, please ask and we will try to address any concerns.

42 CFR Part 2 Prevention Links Recovery Support Division staff is required to keep your personal information, including your involvement with our programs, private. Any information you share with us is protected and only shared with necessary program staff. The only time we will share information about you is if you sign a form that states exactly what information we can share with who and in what format (fax, verbal, email, etc.). This is so that we can work effectively with other organizations that are providing you and your family services, such as a treatment program, a care management organization (CMO), probation, school, etc. We could also be required to share certain information in a limited number of emergency situations (please see below).

The Privacy Rule permits disclosures for “treatment, payment and health care operations” as well as certain other disclosures without the individual’s prior written authorization. Disclosures not otherwise specifically permitted or required by the Privacy Rule must have an authorization that meets certain requirements. With certain exceptions, the Privacy Rule generally requires that use and disclosures of Protected Health Information (PHI) be the minimum necessary for the intended purpose of the use or disclosure.

CONFIDENTIALITY AND EMERGENCY SITUATIONS

We will keep all information private, except in the following situations:
• If a participant reports physical or sexual abuse; then, by New Jersey State Law, program staff must report this to the Department of Youth and Family Services;
• If you sign a release of information to have specific information shared;
• If you provide information that informs program staff that you are in danger of harming yourself or others;
• Information necessary for case supervision or consultation;
• Or when required by law.

If an emergency happens, and you or your parent/guardian need immediate attention, please contact the emergency services in the community (call 911) for those services. We will follow up those emergency services with standard support to you and your family. You may have a copy of this form upon request.

This document certifies that I agree to allow a Peer Recovery Specialist or other Prevention Links staff to contact me and perform other duties as essential to Prevention Links Recovery Support Division programs. I agree that any exchange of contact information (phone numbers, email addresses, physical addresses, etc) with a member of Prevention Links will be done only with mutual agreement between myself and the PL representative.

I understand that my substance use disorder treatment records are protected under federal regulations (42 CFR Part 2 – Confidentiality of Alcohol and Drug Abuse Patient Records) and cannot be disclosed without my written consent. I may revoke this consent orally or in writing at any time. I understand that the revocation will not be effective retroactively for information disclosures that have already occurred. If not previously revoked, this consent will terminate one year from execution of this agreement.

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Consent*

I agree to the privacy policy.

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RECORDS AND INFORMATION RELEASE AUTHORIZATION

(Includes Drug and Alcohol Information)

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I do hereby give permission to Prevention Links Recovery Support Division or Authorized Representative to release the following information from my records:

Select All
Participant information and interview records
Participation in programs
Other

Note: The person whose records are being released has the legal right to have specific information withheld.

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Other:

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This information shall be released to:

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Name(including authorized representative):

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Relationship

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Phone Number

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Fax

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Address

Street Address Address Line 2 City State ZIP Code

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Email

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and the same information to be released back to Prevention Links Recovery Support Division (Staff Name):

- or Authorized Representative.

The purpose or need for this reciprocal disclosure is to:
Share Collateral Information to Coordinate Recovery Efforts

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This information may be given:

Select All
Verbally, by phone or in person
Fax
In writing
A reproduction of the authorization shall be as effective and valid as the original

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Frequency

As needed
Until 1 year from sign date

I understand this consent can be revoked at any time in writing except to the extent that action has already been taken in reliance thereon; and this consent will allow reasonable time needed to accomplish the purpose for which it is given, not to exceed one year.

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Consent*

I agree to the privacy policy.

CONFIDENTIAL: THE WITHIN INFORMATION IS DISCLOSED TO YOU FROM RECORDS WHOSE CONFIDENTIALITY IS PROTECTED BY STATE AND FEDERAL LAW. FEDERAL REGULATIONS (SEC 42CFER-PT2) PROHIBITS YOU FROM MAKING FURTHER DISCLOSURE OF IT WITHOUT THE SPECIFIC WRITTEN CONSENT OF THE PERSON TO WHOM IT PERTAINS OR, AS OTHERWISE PERMITTED BY SUCH REGULATIONS. A GENERAL AUTHORIZATION FOR THE RELEASE OF MEDICAL OR OTHER INFORMATION IS NOT SUFFICIENT FOR THIS PURPOSE. THE FEDERAL RULES RESTRICT ANY USE OF THIS INFORMATION TO CRIMINALLY INVESTIGATE OR PROSECUTE ANY ALCOHOL OR DRUG ABUSE CLIENT.

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EMERGENCY CONTACT AND RELEASE OF INFORMATION

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Any Medications; allergies; Important information needed in case of an emergency:

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Contat Name 1

First Last

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Relationship

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Email

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Home Phone

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Cell Phone

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Work Phone

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Primary Phone Type

Check One

Home
Cell
Work

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Check One:

Okay to Release program participant-related information to this contact
Contact for Emergencies only

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Secondary Emergency Contact

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Contact Name 2

First Last

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Relationship

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Email

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Home Phone

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Cell Phone

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Work Phone

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Primary Phone Type

Check one

Home
Cell
Work

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Check One

Okay to Release program participant-related information to this contact
Contact for Emergencies only

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Additional Details

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Preferred Local Hospital

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Insurance Provider

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Member Name

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Member ID Number

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Group Number

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If possible, atttach a copy of insurance card

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File

Max. file size: 768 MB.

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Complete Forms with Signature

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Participant Signature*

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Date*

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Signature Parent or Guardian (if Minor):*

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Date*

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Signature Witness

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Date