Consent Form
Welcome to Healing Together Group Therapy!

Please read through the information below and feel free to ask your questions about our sessions and/or anything about us. You can reach us at info@buddyjordanfoundation.com.

Once you are ready to participate, please sign this informed consent form below so we will have on our records that you have read the information and that you have been properly informed about the therapy. All information provided will be used for reporting purposes only in the aggregate.

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Adresse e-mail *
Phone number. (Note: this will only be used to provide updates to sessions)
Full Name.
Your Age.
Your City and State.
Your race
Your Gender
CONFIDENTIALITY. We respect each and everyone's right to privacy and confidentiality and we shall make sure to maintain it that way. However, please understand that this is not absolute and is limited to provide for by law. Certain limitations are as follows: Threatening one's self or another that may result in physical harm; An act of physical or emotional abuse against a child or any person; Sexual abuse against a child where the child is living with the abuser; Whenever we are summoned by court order to disclose information against a participant. However, we shall notify you and let you exercise your privilege in the right to deny the disclosure of your records with us. Your prior written consent to release records.
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CONDUCT AND RELATIONSHIP. For safety, it is necessary that the following is required to be complied with by its members: Discussions made within the group session are not allowed to be discussed outside with anyone and should maintain the practice of confidentiality in order to build trust with fellow members; Members should maintain positivity and not induce disrespect among others; Maintain conduct that brings respect to fellow members' thoughts, emotions, or behavior.
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CONSENT. I agree to adhere to the norms and expectations for group therapy as indicated above. I acknowledge that I have had the opportunity to ask questions and such questions were answered clearly and to my satisfaction. Please Type your full name to indicate your consent.
Une copie de vos réponses sera envoyée par e-mail à l'adresse indiquée.
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