By signing this form, I acknowledge that this confidential medical information (including name, age, diagnosis) pertaining to me may be released to ACHA's "Heart to Heart Peer Mentor" assigned to contact me. This information will be transmitted by ACHA staff to the Heart to Heart Peer Mentor and will be kept in their strictest confidence. All communications between myself and my assigned Peer Mentor are intended to be private and confidential. Conversations will never be recorded. Conversations will never be shared with third parties, except under the following circumstances:
- Your health or personal safety is at risk.
- You are a threat to another individual’s health or safety.
- There is a disclosure of physical, sexual or emotional abuse or neglect, which involves a minor, an elderly individual, or a person with a disability.
I also understand that the role of the Heart to Heart Peer Mentor is to offer basic support, information, and referral. Furthermore, I understand that the Heart to Heart Peer Mentor does not replace professional help, attempt to provide psychotherapy or take the place of a physician. I know that ACHA's Peer Mentors do not give medical advice, lend money or provide counseling. Finally, I am aware that this relationship is short term in nature, not to exceed three to six months.
I have received and read ACHA's Heart to Heart program description and realize the following:
- A Peer Mentor is not a therapeutic counselor.
- A Peer Mentor does not dispense medical advice.
- A Peer Mentor is not expected to be a member's main source of support.
I will not act on any perceived medical advice from the Peer Mentor assigned to me without consulting my physician.
