Overview:

Participation Agreement

The Ascent services that are being offered to you include the use of smart phone technology, the ACHESS application and Peer Recovery Support Services (Peer Recovery Coaching) to help in recovery from alcohol and drug dependence and support individuals mental health recovery.

This participation originates from your involvement with an agency in your county. Your participation is voluntary. If you decide to not take part, the services you receive from the agency will not be affected in any way.

The information below is provided so that you will be aware of the nature and extent of the services Ascent will provide.

Ascent will provide the following:

• Ongoing Peer Support Services provided through the use of the ACHESS application as well as through

  phone contact with experienced Peer Recovery Support Specialists (Coaches), 24 hours a day, 7 days a

  week;

• Training on the use of Peer Recovery Support Services and the ACHESS application;
• Recovery information and tools for managing stress;

  As part of your involvement you will be asked to participate and/or agree to the following

• Install the ACHESS application on your phone, including acknowledgement of the end user license agreement (EULA)
• Commit to familiarize yourself and explore the application’s features and benefits;
• Agree to use ACHESS application in the following ways:

o Complete weekly surveys related to your feelings and experiences in recovery;
o Enable and program a GPS feature within the ACHESS application that will detect when you are near

a location you identify as “risky” for you and your recovery;
o Program your BEACON button with at least one support contact you would like to contact in

the event that you need additional support.
o Use the BEACON button for those moments in which you may feel the need for immediate recovery

assistance or support;
o Review discussion board topics on a regular basis (posting is encouraged);
o Be respectful of the diversity of the community membership and refrain from posting any

comments/photos that may be deemed offensive, including but not limited to a member’s race,

ethnicity, gender, sexuality, religion, lifestyle, abilities or culture;
o Refrain from using the application to commit any illegal acts.
o Discuss any change in your interest in participation with Ascent staff

• Agree to communicate with Ascent Peer Recovery Support Providers on a weekly basis via the application or telephone.

Below is information related to the application, confidentiality and Peer Support Services:

ACHESS is the Addiction Comprehensive Health Enhancement Support System; a smart-phone application intended to help people in their recovery from addictions to alcohol or other drugs. CHESS Mobile Health is currently maintaining this application. The application including all data and information resides and is maintained by Chess Mobile Health. CHESS Mobile Health makes updates and changes to the application.

ACHESS and the smart phone can track your location when you activate the GPS feature (please note: Ascent staff do not have access to GPS information which is not collected, tracked or visible to administrators).

Agency Name __________________________

All information shared in the ACHESS application should be considered similar to that of when engaged in any social media. All content you submit, post, or display will be able to be viewed by other users you should only provide content that you are comfortable sharing with others.

You could receive wrong information from the Internet and/or discussion group. However, we will provide simple tips to help you figure out whether you can trust the information you receive from these sources.

ASCENT

Ascent staff will provide ongoing monitoring of the Ascent application populations’ activities on the application, including, but not limited to reviewing posts and messages. Ascent staff believes strongly in the power of honesty and self-expression and encourage free dialogue from all perspectives. Posts may be deleted in rare or exceptional circumstances if: participants request that their OWN post be deleted, or at the discretion of the Ascent staff if content is deemed to be inappropriate and/or disrespectful to community members. Additionally, Ascent staff can disable accounts of any participants who engage in behaviors that include threats toward others, other abusive behaviors towards other participants or other inappropriate and/or disrespectful behaviors.

Ascent Peer Support Staff use contact management software (Five9) to maintain ongoing contact with you and others in Ascent Community. Calls made from and to Ascent Peer Support are recorded and monitored for quality and safety purposes. Call recordings are automatically made and retained for a rolling thirty-day period.

Ascent staff through the ACHESS application will be collecting information on how the smart phone is used. In the process, we may discover behaviors that raise concern about harm to yourself or others. If Ascent staff sees anything that suggests you or others face imminent risk of harm, we will contact appropriate staff members to intervene.

Confidentiality: Ascent staffs are prohibited from disclosing information about treatment for alcohol or drug abuse without my specific written authorization unless a disclosure is otherwise authorized by federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records (42 CFR Part 2).Business Associates agreements exist between CHESS Mobile Health (ACHESS), Five/9 and Ascent that ensures consistent adherence to protection of your personal protected health information.

By signing this form, you are giving permission for your information to be used by and shared with the individuals, companies, or institutions described in this form.

I have read this consent and authorization form. I have had the opportunity to ask questions including those related to the use of my personal information and have received answers to my questions. I agree to participate in the Ascent services and permit Ascent staff to use and share my information as described above.

Your signature indicates that you have read this form, had the opportunity to ask any questions about your participation and consent to participate. You will receive a copy of this form for your records.

Name of Participant (please print): ____________________________________________________________Phone #: ______________________________________ Email: ________________________________ Signature: _______________________________________________ Date: ___________________________

Signature of Ascent Staff:
Signature: _______________________________________________ Date: ___________________________

Confidential Fax # Attention: J. Morgan