Kiosk MPAC

Step 1 of 5

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Section 1: Welcome and Basic Information

MPAC Peer Services Cross-Consent

This form asks for your permission for MPAC Peer Services and selected partner or referral organizations to share limited information with each other.

This may help with:

Peer support
Referrals
Warm handoffs
Follow-up
Care coordination
Emergency or urgent safety response

This form is voluntary. You do not have to sign it.

If you do not sign, MPAC may still provide peer support that does not require sharing information. However, it may limit MPAC’s ability to coordinate referrals, confirm appointments, complete warm handoffs, contact partner organizations, or assist in emergencies.

MPAC Program/Location(Required)

Participant Information

Full Legal Name(Required)

First Last

Preferred Name/Name Used

Date of Birth(Required)

MM slash DD slash YYYY

Phone Number

Emergency Contact Name

First Last

Emergency Contact Relationship

Emergency Contact Phone NUmber

Intake

How did you hear about us?

Friend/Family

Treatment Provider

Probation officer

Emergency Department

Other

Reason for Referral(Required)

Housing

Employment

Education

Connection to treatment

Connection to recovery community

Recovery support

Probation

Overdose

Co-occurring

Multiple treatment episodes

Other

Reason for Referral, if Other:

Race(Required)

Black or African American

Asian

Native Hawaiian/Pacific Islander

Alaska Native

White

Native American

Other

Refused

Race, if Other:

Ethnicity

Hispanic or Latino

Not Hispanic or Latino

Refused

Gender(Required)

Male

Female

Transgender

Non-binary

Other

Refused

Gender, if Other:

Do you have health insurance?(Required)

Yes

Unknown

Where do you live?(Required)

Housed

Unhoused

Shelter

Recovery Residence

Residential Treatment

Institution

Halfway House

Other

Refused

Describe your living situation, if Other:

Please select which recovery path(s) you use.

Abstinence

12-Step Recovery

Support groups

Natural Recovery

Peer Recovery support

Medication-assisted Recovery

Harm Reduction

Alternative/Holistic Recovery

Other

Unknown

Recovery Path, if Other:

Acknowledgement(Required)

I understand that this form is voluntary and is used only for limited peer services coordination.

Cross-Consent Choices

Who May Share Information?

Please choose what kind of information sharing you allow.

I allow MPAC to share limited, non-clinical peer services information with partner/referral organizations I select or request.

I allow partner/referral organizations to share limited, non-clinical referral or coordination updates back to MPAC.

I allow two-way communication between MPAC and selected partner/referral organizations for peer support, referrals, warm handoffs, care coordination, and follow-up.

I allow MPAC to share limited information only in an emergency or urgent safety situation.

I do not allow MPAC or partner/referral organizations to share information at this time, except as required or permitted by law.

Partner or Referral Organizations

Please list the people or organizations MPAC may contact or receive information from.

Organization

Person

Name

Contact Person, if known

Phone or Email, if known

Do Not Share With

Please list anyone you do not want MPAC to contact or share information with.

(Optional)

I do not have anyone to list at this time.

Section 3: What Information May Be Shared

Limited Information Only

MPAC and selected partner/referral organizations may share only the limited, non-clinical information needed for the purpose selected.

Information that may be shared:

My name, preferred name, contact information, date of birth, or other information needed to confirm my identity or complete a referral.

My participant-stated needs, goals, preferences, barriers, or requested resources.

Referral information, including referral source, referral destination, appointment date/time/location, transportation needs, documents needed, and referral follow-up status.

Peer services participation information, such as dates of contact, attendance, engagement status, completion of a non-clinical peer activity, or closure status.

Non-clinical peer services notes limited to resource linkage, care coordination, warm handoffs, outreach attempts, participant-stated preferences, and follow-up tasks.

Emergency contact information and safety-related facts needed to respond to an urgent situation or coordinate emergency help.

Information needed to support housing, benefits, employment, education, transportation, digital access, legal aid, recovery support, treatment referral, or other community-based referrals.

Other limited information.

Limited Information, if Other:(Required)

Please describe what other limited information may be shared.

Information Not Included

This form does not allow MPAC to release full clinical, medical, mental health, substance use treatment, insurance, or billing records.

This form does not authorize the release of:

Diagnoses
Clinical assessments
Treatment plans
Therapy notes
Counseling notes
SUD counseling notes
Medication lists
Lab results
Drug screen results
HIV/STI test results
Psychiatric records
Hospital records
Billing or insurance records
Full medical records

A separate authorization may be required if a clinical provider or program needs to release clinical information.

Acknowledgement(Required)

I understand that this form is for limited, non-clinical peer services information only.

Section 4: Purpose, Rights, Emergency Sharing, and Expiration

Why Information May Be Shared

The information may be shared only for the purposes selected below.

Peer support planning and follow-up requested by me.

Care coordination and communication among people or organizations helping with my peer services goals.

Referrals to treatment, recovery support, harm reduction, housing, benefits, employment, education, transportation, digital access, legal aid, or other community support.

Warm handoffs, appointment scheduling, referral confirmation, and follow-up on whether a referral was completed.

Emergency, urgent safety, or crisis coordination when needed to protect my health, safety, or wellbeing or the safety of another person.

Information sharing that I specifically request.

Please describe your request.(Required)

Emergency or Urgent Safety Situations

If MPAC reasonably believes there is an emergency, urgent safety concern, overdose risk, risk of serious harm, medical crisis, or other crisis situation, MPAC may contact emergency medical personnel, crisis response services, 911, 988, a hospital, mobile crisis, or my listed emergency contact.

MPAC should share only the information necessary to respond to the situation.

My Rights

Signing this form is voluntary.
I may refuse to sign this form.
I may ask MPAC to limit what is shared or who it is shared with.
I may request a copy of this signed form.
I may revoke this consent in writing at any time.
Revocation will not affect information already shared before MPAC receives and processes my written revocation.

When This Consent Ends(Required)

One year from the date I signed this form.

When my participation in MPAC Peer Services ends or my referral coordination needs have been completed.

Specific expiration date.

Other expiration events.

Expiration Date(Required)

MM slash DD slash YYYY

Please describe the expiration event.(Required)

Acknowledgement(Required)

I understand my rights, how emergency sharing works, and when this consent ends.

Section 5: Review, Signature, and Staff Completion

Review Before Signing

By signing below, I confirm that:

I have read this form or had it explained to me.
I had the opportunity to ask questions.
I understand that this form allows limited cross-consent between MPAC and selected partner/referral organizations.
I understand what information may be shared.
I understand who information may be shared with.
I understand why information may be shared.
I understand that clinical records, treatment records, therapy notes, medication information, lab results, drug screen results, and full medical records are not covered by this form.
I understand that I may revoke this consent in writing.

Participant Signature(Required)

Date Signed(Required)

MM slash DD slash YYYY

Parent, Guardian, or Legally Authorized Representative, if required

Is a parent, guardian, or legally authorized representative signing for the participant?(Required)

Yes

Representative Signature(Required)

Representative Printed Name(Required)

Relationship to Participant(Required)

Date Signed(Required)

MM slash DD slash YYYY

MPAC Staff / Witness Completion

MPAC Staff or Witness Name and Title

Program / Location

Did the participant receive or request a copy?

Yes

Were restrictions or special instructions noted?

Yes

Restrictions or special instructions