Consent Form | I Have A Say

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INFORMED CONSENT FOR VIRTUAL SUPPORT GROUP SESSION

General Information

This Informed Consent (“Form”) will provide a clear framework for what to expect in the [virtual support group] sessions (“Session”). Feel free to discuss any of this information with me so I can ensure your questions are answered. Please read and indicate that you have reviewed the information and agree to participate in the Session by initialing where required and signing the end of the Form.

Confidentiality¹

I Have A Say values your privacy and wants to ensure you are informed about our confidentiality policies. Please review the following statements and initial the line to the left to indicate that you understand and agree to the statement.

I Have A Say will not provide, disseminate, sell, or otherwise disclose your identity or personal information to any outside person or entity without your express written consent.

I Have A Say may use aggregated and de-identified data to compile statistics, perform community outreach, and refine its offered services.

Notwithstanding the foregoing, I Have A Say may disclose your identity and personal information upon any of the following conditions:

Client threatens or attempts to commit suicide or otherwise conducts him/her self in a manner in which there is a substantial risk of incurring serious bodily harm.
Client threatens grave bodily harm or death to another person.
If I Have A Say or any guest speaker has a reasonable suspicion that a Client is the perpetrator, observer of, or actual victim of physical, emotional, or sexual abuse of a child under the age of 18 years.
If I Have A Say or any guest speaker has a reasonable suspicion that a Client is the perpetrator, observer of, or actual victim of physical, emotional, or sexual abuse of a person over the age of 65.
In response to a legitimate subpoena or other legal process, but only to the extent required by law. I Have A Say will make reasonable efforts to notify you before responding to such subpoena or legal process.
In order to defend itself against any claim, complaint, allegation, or public statement made by Client against I Have A Say.

¹ I Have A Say is not covered by the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) or any subsequent federal legislation. While I Have A Say intends to safeguard your personal information as described herein, it is important you understand that the HIPAA privacy rule and other limitations on disclosure of information are not applicable to I Have A Say or to any information shared in the group Sessions.

Given the group setting of the Session, there are limitations to confidentiality that are outside I Have A Say’s control and I Have A Say cannot ensure that all Session participants will safeguard Client’s identity and personal information.

If any employee, representative, agent, or guest speaker of I Have A Say sees Client outside of the Session, such person will not acknowledge Client first. If Client chooses to engage such person, he or she will be happy to speak with Client briefly but will not engage in any personal, extended, or otherwise sensitive discussion with Client.

Terms of Participation

In order to participate in the Session, you agree to abide by and be bound by the following terms. Please review the following statements and initial the line to the left to indicate that you understand and agree to the statement.

Client will help to create a safe, confidential, and positive environment for all Session participants. In order to promote this environment, Client will:

treat each Session participant, guest speaker, and I Have A Say representative with respect.
avoid using any derogatory, judgmental, hurtful, or disrespectful language when addressing a Session participant, guest speaker, and I Have A Say representative.
keep the identity and personal information of every Session participant, guest speaker, and I Have A Say representative confidential.
take all reasonable precautions to safeguard the identity and personal information of every Session participant, guest speaker, and I Have A Say representative.
NOT record, transcribe, share, cast, or otherwise disseminate or attempt to disseminate the contents of any Session, including the identity and personal information of Session participants, guest speakers, and I Have A Say representatives.
NOT acknowledge any Session participant outside of the Session.
NOT attempt to contact any Session participant outside of the Session (if Session participants wish to contact one another outside of the Session, they may request each other’s contact information from I Have A Say and provide written authorization to disclose their identity and personal information to the other Session participant).

Client may authorize disclosure of her identity and personal information to any person or entity in writing by directing such written authorization to I Have A Say, PO Box #32842 Phoenix, AZ 85064.

Client authorizes I Have A Say to use their de-identified data to compile statistics, perform community outreach, and refine its offered services.

Client may request to participate in the Session using an alias and/or avatar, which request shall not be unreasonably denied. Client must make such request prior to the Session so that appropriate steps may be taken to safeguard Client’s identity and personal information.

Failure to abide by any term of this Form is grounds for immediate removal from the Session. If Client is removed from a Session due to a violation of this Form, Client forfeits the cost of the Session and may be barred from all future I Have A Say programs without further warning.

Limitation of Service

Nothing in this form shall be construed as creating a physician-patient, psychologistpatient, psychiatrist-patient, or similar relationship between I Have A Say and Client.

I Have A Say does not perform any function on behalf of, or provide any service to, a covered entity as that term is defined in the health insurance portability and accountability act of 1996 (45 CFR § 160.103).

The statements of guest speakers do not necessarily reflect the views and beliefs of I Have A Say or its representatives.

BY SIGNING THIS FORM, CLIENT AGREES THAT SHE HAS READ, UNDERSTOOD, AND AGREED TO THE TERMS CONTAINED IN THIS FORM.

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INFORMED CONSENT FOR VIRTUAL SUPPORT GROUP SESSION

BY SIGNING THIS FORM, CLIENT AGREES THAT SHE HAS READ, UNDERSTOOD, AND AGREED TO THE TERMS CONTAINED IN THIS FORM.

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