Second Chance AA Meeting Agreement

Thank you for your interest in the Alcoholics Anonymous (AA) Second Chance Meeting hosted here at the Transplant House of Cleveland. Our meeting is held only via zoom at this time, but we look forward to when we can have participants both in person and virtually. The meeting is a closed AA meeting that is open only to patients that have an addiction issue and a medical problem with a possible need for an organ or tissue transplant.

Though you may have been referred to this meeting by your Cleveland Clinic or University Hospital Transplant team(s), we at The Transplant House are a separate organization. We do not have access to your medical records or information. Also, your participation is completely voluntary. All information shared in the meeting is strictly confidential.

If you would please fill out all the following information, it would be very helpful for us!

Name(Required)
Address(Required)

Next of kin in case of emergency

Name(Required)
Address(Required)

Additional information

Hospital Transplant Team(Required)
Who referred you to the AA meeting:(Required)
Status(Required)
Do you need confirmation of your AA attendance and participation shared with anyone such as your Social Worker, Coordinator, Doctor, Probation Officer, etc.?(Required)
If yes, please provide their name, title and contact information:
Name
By checking this box and writing my initials, I am requesting and giving consent to share my AA participation with the person written above.
By checking this box and writing my initials, I agree that all information shared in the meeting will remain confidential about myself or others participating.(Required)
By checking this box and writing my initials, I understand that I if I break confidentiality of information or act improperly, I will not be allowed to participate future meetings.(Required)
By checking this box and writing my initials, I understand that I am not allowed to record any part of the meeting. Also, my camera or phone must be on throughout the meeting to verify that it is you participating.(Required)
Please type your name.
MM slash DD slash YYYY
Enter today's date.

This consent will expire 6 months after the date of your last AA mtg attended.

Thank you for your interest in the Second Chance AA mtg at the Transplant House of Cleveland. We meet every week on Wednesday from 10-11 am. We will provide a Zoom link for the meeting. When it is safe to do so considering COVID, we will offer the meeting both in person and by Zoom.

Please direct any questions to:

Annette Humberson, LISW-S
Transplant House of Cleveland
Annette work phone #: (440)340-3905
Transplant House phone #: (216)938-9553

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