You havebeen identifiedas a potentialparticipantin Ohio’s First Episode Project (FEP). As a result,youmaybeeligible for certainbehavioral treatment and support servicesofferedthrough this project.Yourparticipation isvoluntary.
BackgroundInformation:Thepurposeof this project isto address theunique needs ofindividuals livingwith mental health issueslivingin thecommunity;and to determine throughanevaluationprocess ifselected treatment and supportinterventionsimpactparticipantwellnessandsuccesswithin the community.
Procedures: Whileenrolled in theFEPprogram, we mayaskyou to participate in thefollowingthings:
1.On-goingassessments to assistyou in determiningyourtreatmentand supportneedsand to develop andmonitoryourindividualizedcase plan.
2.Ongoing confidential interviews, at thebeginningof the program,every sixmonths while you are in the program, andat its completion.Eachinterviewwilllast approximately30minutes and will occur atamutuallyagreed upon locationandtime. You will beasked questionsaboutyour satisfaction with the services that have been providedandaboutvarious aspects ofyour life, includingyourhousing, health, mentalhealth,employment,criminaljustice involvement,andoverall functioning.Wewill beusingthe datawe collectfromyou to evaluateif participants’qualityoflifeimproves as aresult of the program.Yourparticipationin the evaluationcomponent ofthe programis voluntary. Ifyouchoosenot to participate intheevaluation, it will not affectyourcurrentservices,yourrelationship withyourcase managerorother treatment providers, oryourhousing, employment or status at school.Ifyou decideyou donot want to participate anylongeryoucan tell yourtreatmentprovider.
Risks andBenefits toparticipating inOICP services andstudy:Theonlyforeseeablerisk of participatingis thepossibilityofexperiencingsomeemotionaldistresswhen answeringsomequestions. If such feelingsarise,youmayskip the question, ordiscuss them withyourtherapist or case worker. You maybenefit from theservicesprovided.
Who is collecting the information: TheFEP Program is fundedbytheOhio Department of Mental Health and is beingadministeredby your treatment provider.
Confidentiality:Yourrecords will be kept privateasrequiredbylaw.Everythingwetalk about will be between us and the project staff.Theonlyexception is if you talk aboutharmingyourself orsomeone else. Bylawweare required to report ifyouareplanningtoharmyourself or others.
Inaddition:
√All assessmentresponses thatyou providewill onlybeused to assistyouin addressingyour short and longtermrecoverysupport needs. It willnot be shared withanyonewithoutyourwritten, informed consent.
√Service evaluation information will godirectlyinto a computer program (GPRAdatacollector). Your responseswill only be able to be viewed by a data analyst or your treatment provider for treatment planning purposes.When reporting the results of the program, your answers to the questions will be put together with manyotherpeople’s answers and therewill beno wayto know whose answers arewhose.Inanyreportwe might publish, wewill not include anyinformation that will make it possible toidentifyyou. Access to the records will be limited to the projectstaff only.
Statement ofUnderstanding andConsent
Iunderstand that myalcohol and/ordrugtreatmentrecords areprotected under thefederalregulationsgoverningConfidentialityof Alcohol and DrugAbusePatientRecords, 42 C.F.R.Part2, and the HealthInsurance PortabilityandAccountabilityAct of1996 (HIPAA), 45C.F.R. Pts. 160 and 164 and cannot be disclosedwithoutmywrittenconsentunlessotherwiseprovidedfor in theregulations. Ialso understand thatImayrevoke this consent atanytime except to the extent that actionhasbeen taken in relianceon it.
Ihave read theabove information. Ihavereceivedanswers to questionsIhaveasked.
Iagree to participatein theFEPProgram.
Iconsent to participation inFEPProgramconfidentialsurveysand programevaluation andI am at least 18years of age.
Iagree to shareinformation regardingmytreatmentandservicesIreceiveas a resultofthis grant.
Ihavebeen providedacopyof this form.
SignatureDate
WitnessDate
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