I agree to participate in progress monitoring research designed to improve the effectiveness of the treatment I receive during the time I am enrolled at Peaks Recovery Center (“Peaks”). This monitoring will include information about potential mental health conditions, current and previous drug and alcohol use, and satisfaction with treatment. I understand that this monitoring will be conducted by Vista Research Group, Inc. (“Vista”) using online surveys, and that all information I provide while I’m attending this treatment program will be immediately shared with the clinician(s) and/or the leadership of Peaks so that it can be used to improve my treatment. I agree that Vista may use email or text messaging to send me links to the surveys as well as a copy of this consent form.
I also agree that Vista may contact me periodically during the first 13 months after I leave Peaks to ask me questions about my recovery. This post-treatment outcomes research is designed to help Peaks improve the treatment it provides to future clients. Since I am not benefitting directly from this portion of the research, Vista will provide me a small stipend in appreciation for my time.
Vista will keep my post-treatment survey responses confidential unless otherwise required by law or permitted under this agreement. Vista will provide my responses to the leadership of Peaks only after Vista deidentifies the information and combines it with the responses of other patients. However, I agree that Vista may notify Peaks if I specifically indicate that I am interested in returning to active treatment at Peaks.
Additionally, I agree that Vista may contact Peaks and appropriate law enforcement agencies if Vista reasonably believes, based on my communications with Vista, that I have made a serious threat to physically harm myself or others. I understand that Vista is NOT my healthcare provider or a crisis line; Vista does not assume any duty to warn or protect me or others from harm.
I give Vista permission to send me links to the surveys, gift cards, and a copy of this agreement by email or text. I also give permission for gift cards and a copy of this agreement to be sent to me through the mail, and for Vista researchers to call me if they are unable to reach me via email or text.
I also agree that Peaks may share with Vista my name, medical record number, birthdate, gender, phone number(s), email address, the name and type of my health plan, the name(s) of my primary clinicians, and the dates and reasons why I am admitted, transferred and discharged from Peaks’s program(s).
I understand that health information that may be used to identify me is protected under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and 45 C.F.R. Parts 160 and 164. The confidentiality of my health information may also be protected under 42 C.F.R. Part 2. I understand that my personally-identifiable health information and/or substance use disorder records cannot be disclosed without my written consent unless otherwise provided for by federal law or regulation.
I understand that this authorization expires 13 months after I have left Peaks, and that I have the right to revoke this authorization at any time by emailing research@vista-research-group.net. I understand that my enrollment at Peaks is not contingent upon my involvement in this research.
Finally, if I am a minor, I understand that a parent or guardian will also be asked to agree to my participation in this research, unless state law allows me to consent to treatment on my own and I request that my parent or guardian not be notified.