Inter-Tribal Council of Michigan (ITC) Behavioral Health
Access to Recovery, Anishnaabek Healing Circle
Informed Consent for Evaluation/GPRA
You are being asked to participate in aneffort to evaluate the services you will receive from the Access to Recovery (Anishnaabek Healing Circle program) you have elected to participate in. We have prepared this form to provide you with all of the information you will need to make an informed decision about your participation in the evaluation of the program. Feel free to ask questions during any point of the explanation.
What is the Purpose of the Project?
TheAccess to Recovery (Anishnaabek Healing Circle program) is designed to provide client choice among substance abuse clinical treatment and recovery support service providers, expand access to a comprehensive array of clinical treatment and recovery support (including faith-based/culturally-based programmatic options) and to increase substance abuse treatment capacity through a voucher system of payment. The program is federally funded by the Center for Substance Abuse Treatment. The Inter-Tribal Council of Michigan is responsible for the management and evaluation of this program. Because you are receiving services from one of the participating providers, you are invited to participate in this evaluation.
What information will I be asked to provide?
To evaluate this program we will need to collect information aboutyour current living situation, your involvement with other health treatment facilities, your substance abuse (both past and present), your employment or educational status, your involvement in cultural activities, your legal status, and your health. As part of the program evaluation, you will be asked to complete an initial evaluation interview at intake and additional interviewsat discharge and at 6 months post intake. Each interview will last about 30 minutes.
How will my privacy be protected?
The information you provide will always be treated confidentially. Specifically, the information you provide will be coded with a special ID number. Only yourCare Coordinator will be able to associate your name with the ID number that appears on the data collection forms. If yourCare Coordinator requires assistance in locating you for follow-up interviews your name will be given to another member of the treatment program staff to assist with locating you and completing the interview. This person is covered by the same confidentiality requirements as your Care Coordinator and will insure that information you provide in the follow-up interview will be treated confidentially.
In what way will the information gathered be used?
Your responses to the evaluation questions will be kept in your confidential client file at the service provider’s program office. Your Care Coordinator will use the initial information collected to help plan services for you. Forms that include your responses only, with no name or other identifying information, will also be provided to the Inter-Tribal Council of Michigan for use in the evaluation of the program. The Inter-Tribal Council staff will enter you data into a data base along with other clients. This data base will be used by the ITC Management Team to examine program outcomes. The Inter-Tribal Council will also submit your anonymous information to the Federal funding agency via a secured electronic data base that will allow decision makers at the Federal funding agency to view reports about the program.
Your name will not come to the attention of representatives of the Federal Government or any other persons reading reports produced by this project. Furthermore, the information reported to the Federal Government will always be grouped with information from other people so that you cannot be identified. This project is being conducted by Inter-Tribal Council of Michigan, under Grant # 1H79TI025514funded by the Substance Abuse and Mental Health Administration(SAMHSA).
Are there any risks involved with my participation?
The main risk associated with your participation in the evaluation is that someone you have not authorized could gain access to the personal information about your life, including any substance use that may have occurred. While it is possible that your confidentiality could be broken, strict measures will be put in place to protect your confidentially. There are already federal laws which protect the confidentiality of substance abuse treatment clients and anyone who breeches this confidentiality may be liable for a fine. Furthermore, to protect against the risk your responses to evaluation questions will only be identified with a code number, no identifying information such as name, address, or phone number will on the forms. All evaluation records will be kept in locked filing cabinets in secured offices.
Are there any benefits?
All participants in this evaluation may benefit directly from the clinical treatment and recovery support services they receive as well as through increased pride in knowing that they are participating in an effort to help improve counseling and recovery for other Native American people. If we learn how to better treat alcohol and other drug abuse in Native American people, then this evaluation will benefit others across the nation.
Your Participation is Voluntary.
Your participation in this evaluation is strictly voluntary. Your treatment or receipt of recovery support services will not be affected by you choice to participate in the evaluation. However if the project is not able to collect data required by the funding agency the services you receive will not be paid for by the project.
What if I have questions? You will receive a copy of the consent forms for your records. If you have questions about the evaluation you can discuss these with your counselor or you can call the project staff at Inter-Tribal Council of Michigan. They will be happy to answer your questions. ContactCora Gravelle, Inter-Tribal Council of Michigan at 1-800-945-7332.
Consent
This project has been thoroughly explained to me. I have been allowed the opportunity to ask questions concerning any and all aspects of the project and procedures involved. I understand that the evaluators and the program staff have set up procedures to protect the confidentiality of records related to my involvement in this evaluation. My signature below indicates that I consent to participate. It does not, however, obligate me to participate. My consent to participate will last for 6 months after I stop receiving services from the Access to Recovery programand must be renewed if I am to be contacted after that.
Participant: By signing below, I hereby agree to participate in the above-described evaluation.
______/___/___
Participant SignatureDate
Print Participant Name Clearly
Parent/Guardian: By signing below, I hereby give permission for minor child ______to participate in the above-described evaluation.
Relationship: ____Parent
____Family/Guardian
____Other: ______
Parent/Guardian
______/___/___
WitnessDate
Anishnaabek Healing Circle ATR Client Consent for GPRA & EvaluationPage 1
2010 (11-13-14)