Healthcare Harm Reduction Form

HEALTHCARE HARM REDUCTION FORM

Patient Information

Patient Name:

Date of Birth:    Gender/Identity:

Emergency Contact

Insurance (if applicable)

Medical History

Harm Reduction Services Requested

Indicate the services you are requesting (check all that apply):

Naloxone (overdose reversal) distribution/training

Syringe/needle exchange and safer injection supplies

Safer smoking supplies and education

Wound care supplies and wound care instruction

Voluntary testing (HIV, HCV) and referral

Overdose prevention education and behavioral counseling

Risks, Benefits, and Acknowledgments

I acknowledge that harm reduction services are intended to reduce health risks associated with substance use and related behaviors. The benefits of these services may include reduced risk of infection, reduced risk of overdose, and improved access to health care and social supports. I understand there may be residual risks, including but not limited to infection, injury, or adverse reactions to supplies or interventions provided.

I understand that the provider does not require abstinence and does not diagnose or treat substance dependence through these services. I accept that receipt of supplies or training does not eliminate all risk and that I remain responsible for my own safety and actions.

I acknowledge that staff have explained how to use distributed supplies safely, how to store and dispose of supplies, and how to recognize and respond to an overdose. I understand I may decline any supplies or training at any time.

By initialing below I confirm I have received verbal instruction and written materials where applicable and have had the opportunity to ask questions.

Initials:

Privacy, Confidentiality & Limits

Information collected for the purpose of providing harm reduction services will be treated as confidential and used to provide services, referrals, and to document distributed supplies. Protected health information may be disclosed only with the client's written authorization, except as required by law. Exceptions include reporting of child abuse or elder abuse, instances where there is a reasonable belief of imminent risk of serious harm to the client or others, and legal process such as a court order.

I authorize the limited sharing of my information as needed for provision of services and referrals to community partners, subject to applicable law and written agreements limiting further disclosure.

Authorization to share information for continuity of care may be revoked in writing at any time, except to the extent that action has already been taken in reliance on this authorization.

I acknowledge the confidentiality statement and limits described above.

Legal Certifications & Consent

I voluntarily request and consent to receive harm reduction services and supplies from this program. I understand these services are provided as part of a public health program. I acknowledge that the provider has explained the nature, purpose, and expected benefits of the services and the reasonable foreseeable risks. I have had the opportunity to ask questions and obtain answers to my satisfaction.

I release the provider and its staff from liability for harm that may result from my participation in voluntary harm reduction services, except to the extent caused by the provider's gross negligence or willful misconduct as determined by a court of competent jurisdiction.

I understand that I may withdraw consent at any time, and withdrawal will not affect any actions already taken with my prior consent.

Authorization expires on:

I have read and understand the risks and benefits described above and consent to receive the indicated harm reduction services.

Additional Notes (staff use or client request)

Sign Now