PIK Consent

Participant Name*
First Last
Date of Birth*
MM slash DD slash YYYY
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
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My Program is:*
- Prevention is Key
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*
Enter 111-111-1111 if you do not have a phone.
Can we leave a voicemail?*
- Yes
- No
Participant Email

Enter no@email.com if you do not have an email.
Forms to be Completed
New Participants must complete a consent form. The other forms are optional.
Forms to be Completed*
- Select All
- Consent to Receive Services
- Release of Information
- Emergency Contact
- Media Consent
- OHH Consent
At least one form must be completed. New participants should at a minimum complete the Consent to Receive Services.
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Person Completing Form:*
- Participant (adult)
- Not the Adult Participant
- Participant (minor)
- Parent or Guardian of minor

INFORMED CONSENT, PRIVACY AUTHORIZATION, AND PARTICIPANT AGREEMENT
This document is meant to explain Prevention is Key program policies, State and Federal laws, and your rights. It also serves as an agreement to participate voluntarily in Prevention Is Key programs. If you have other questions or concerns, please ask and we will address any concerns.

42 CFR Part 2 Prevention is Key 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 community 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 of a minor; then, by New Jersey State Law, program staff must report this to the Department of Child Protection and Permanency;
• If you sign a release of information to have specific information shared;
• If you provide information that informs program staff that you are imminently 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 Prevention is Key staff member to contact me and perform other duties as essential to Prevention is Key programs. I agree that any exchange of contact information (phone numbers, email addresses, physical addresses, etc) with a member of Prevention is Key will be done only with mutual agreement between myself and the Prevention is Key representative.

I understand and agree to the following:

• I understand that I am agreeing to receive services from a Prevention is Key representative(s), which could include recovery coaching, telephone recovery support, CRAFT, recovery meetings, recovery trainings, community events, or others.
• I understand that if at any time I desire a referral to services not provided by Prevention is Key (e.g., mental health treatment, transportation, substance detox, etc.) I will be assisted in finding such services.
• I understand that if I decide to discontinue receiving services from Prevention is Key, I will notify my recovery coach, or call CARES at 973.625.1143
• 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.
Consent*
I agree to the privacy policy.

MEDIA CONSENT FORM
I permit and authorize Prevention is Key (PIK), and its employees, agents, representatives, contactors, and personnel who are acting on behalf of PIK to create and/or obtain and use my photograph, my voice or quotes/excerpts of my written or verbally expressed words, my artwork or a photograph of my artwork, my name, alias, or biographical information, a video and/or audio recording or other likeness of myself (herein collectively referred to as “My Likeness”) for purposes related to the educational mission of PIK, including publicity, marketing, and promotion of purposes related to the educational mission of PIK, including publicity, marketing, and promotion of PIK and its various programs without compensation to me. I understand My Likeness may be copied/reproduced and distributed by means of various media, including but not limited to, video presentations, simultaneous television broadcast/rebroadcast, radio transmission/retransmission, news releases, mail-outs, e-mails, billboards, signs, brochure, placement on websites and/or other electronic delivery, publication, display, or promotion on any and all other media, and I further understand that My Likeness may be subject to reasonable modification or editing. I acknowledge that PIK has the right to make one or more photographs, audio recordings, videotape or disk presentations, or other electronic reproductions of My Likeness in accordance with this Authorization for Use of Image Voice, Performance, Artwork or Likeness (hereafter referred to as “this Authorization”). I waive any right to inspect or approve the finished product or material in which PIK may eventually use my Likeness. I relinquish and give PIK all rights, title, and interests in and to My Likeness, including any copyright therein. This Authorization shall be binding upon my heirs, successors, assigns, and legal representations. I understand that, although PIK will endeavor to use My Likeness in accordance with standards of good judgement, PIK cannot warrant or guarantee that any further dissemination of My Likeness will be subject to PIK’s supervision or control. Accordingly, I release PIK from any and all liability related to the dissemination, reproduction, distribution, and/or display of My Likeness in print or any and all other Media, and any alteration, distortion or illusionary effect of My Likeness, whether intentional or otherwise, in connection with said use. I also understand that I may not withdraw my permission for use of My Likeness which was granted in this Authorization By signing below, I acknowledge that I have read and understand the conditions of this Authorization. Furthermore, I represent that I am of legal age, have full legal capacity and am authorized to sign on behalf of myself.
I grant Prevention is Key and affiliates to use my full name.*
- Yes
- No
I grant Prevention is Key to use my full first name and last initial.*
- Yes
- No
I grant Prevention is Key to use my story but with a false name.*
- Yes
- No
Consent*
I agree to the media consent policy.

Operation Helping Hand - Consent for Services
The below statement should be read and explained to all individuals:
When a person is arrested, they are informed of the availability of recovery support services and/or treatment resources through Prevention is Key.
Operation Helping Hand (OHH) goal is to link individuals to detox, substance use disorder treatment and continued recovery support services.
Please sign below, acknowledging that a Prevention is Key Representative provided you with information about Operation Helping Hand resources prior to release and that you: AGREE/DISAGREE (Choose One) to meet with the program’s recovery specialist.
Chose One*
- AGREE
- DISAGREE
I AM WILLING TO KEEP IN CONTACT WITH THE RECOVERY SPECIALIST. I HAVE BEEN GIVEN THE RECOVERY SPECIALIST’S PHONE NUMBER.

Complete Forms with Signature
Participant Signature*
Date*
MM slash DD slash YYYY
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Signature Parent or Guardian (if Minor):*
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Date*
MM slash DD slash YYYY
Signature Witness
Witness Name
Date
MM slash DD slash YYYY

Step 1 of 7

Forms to be Completed

INFORMED CONSENT, PRIVACY AUTHORIZATION, AND PARTICIPANT AGREEMENT

RECORDS AND INFORMATION RELEASE AUTHORIZATION

This information shall be released to:

EMERGENCY CONTACT AND RELEASE OF INFORMATION

Secondary Emergency Contact

Additional Details

If possible, attach a copy of insurance card

MEDIA CONSENT FORM

Operation Helping Hand - Consent for Services

Complete Forms with Signature