Indigenous Wellbriety Online Participation Agreement
Greetings! Please read and agree to the terms of the Talking Circle participation online. 

NOTE: Your personal information will NOT be shared with organizations. We ask for this form so we can maintain contact with our participants. Thank you. 

Expectations of Participants

If you wish to receive help through the Indigenous Wellbriety Program, please understand that the Indigenous Wellbriety Program Provides:

  • Wellbriety Talking Circles
  • Referrals to Community Resources
  • Education through Wellbriety
  • Peer support from IWP Team
  • Sober Community Cultural Activities

Reminders:

  • Indigenous Wellbriety Program is operated as a non-profit with fiscal sponsorship by United Way Southwest Colorado.

  • We will collect data for evaluation purposes and to report to IWP grant funders. 

  • We may take pictures to help promote the program

  •  Financial assistance for the program has been attained through local & statewide grants. This service is free until funds are no longer available.

  • As a participant, you are expected to honor your peers, respect each other, hold safe space and take turns in giving one another a chance to speak. 
  • Please do not use obscenities and if you need to step away, please let us know in chat or message a peer recovery coach facilitator. 

Preparations for Participation:

  • Complete this consent form before you engage in Talking Circles and submit.
  • Sign agreement to participate in the following ways:
  • Attend weekly class sessions and be prepared for 1 to 2 hour sessions (depending on class size).  If you will be missing a class, please notify IWP Team. 
  • Complete all surveys and/or evaluations. 

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Which Talking Circle Are you participating in?  *
Name (First, Last) *
Mailing Address:  Include City, State & Zip Code *
Email Address:  *
Phone Number:  *
I understand that what is shared in Talking Circles stays in Talking Circles.  *
Required
I will provide a safe confidential space for my peers and the interaction by being in a room alone or wearing headphones when I am in session in an Indigenous Wellbriety Talking Circle.  *
Required
Are you okay with screenshots of you being taken? 
 *
Date *
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By Signing Here, you will submit your typed name and confirm that you agree to contents of the Online Participation Agreement.  *
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