Healthcare Group Work Waiver

HEALTHCARE GROUP WORK WAIVER

Client Name:    Date of Birth:

Contact & Demographic Information

Gender: Male Female Other Prefer not to say

Emergency Contact

Insurance Information

Medical History

Group Work Description

Description of Group Activity:

Risks, Benefits, and Acknowledgements

I understand that participation in group work may include emotional, psychological, and interpersonal risks including but not limited to discussion of sensitive topics, differences of opinion, and temporary distress. Participation does not guarantee therapeutic outcome.

I acknowledge that the benefits may include peer support, skill development, and therapeutic insight, but results vary and no guarantee is made.

I have read and understood the risks and benefits described above.

Confidentiality & Limits

Confidentiality will be maintained among participants and staff to the extent permitted by law. Exceptions to confidentiality include: imminent risk of harm to self or others, suspicion of abuse of a minor or dependent adult, court order, or other legal obligations. Information shared in group may be discussed with clinical staff for treatment or safety reasons.

I understand the confidentiality parameters and limits described above.

Emergency Treatment Authorization

In the event of an emergency during group activities, I authorize licensed staff to obtain or provide emergency medical treatment, including transportation to a medical facility, as deemed necessary for my safety.

I authorize emergency medical treatment as described above.

Release of Liability & Indemnification

By signing this Waiver, I voluntarily assume all risks associated with participation in the group work and agree to release, waive, discharge, and covenant not to sue the healthcare provider, its employees, agents, and volunteers for any claims of liability for personal injury, emotional injury, property loss, or wrongful death arising from my participation, except to the extent resulting from gross negligence or willful misconduct. I agree to indemnify and hold harmless the provider from any third-party claims arising from my actions during group activities.

I agree to the Release of Liability and Indemnification terms above.

Media & Recording Consent (Optional)

Sessions may be observed or recorded for training or clinical supervision only with advance notice. Recordings are subject to confidentiality safeguards.

I consent to observation or recording of sessions as described above.

Right to Withdraw

Participation is voluntary. I may withdraw from group activities at any time without penalty to other ongoing treatment services, subject to clinical safety considerations. Withdrawal should be discussed with a clinician when possible.

I understand my right to withdraw and the process for doing so.

HIPAA & Privacy Acknowledgment

I acknowledge that I have been offered a copy of the provider's Notice of Privacy Practices and that I understand how my protected health information may be used and disclosed in connection with group services, treatment planning, billing, and legal requirements.

I acknowledge receipt of the Notice of Privacy Practices and understand how my information may be used.

Acknowledgment & Certification

By signing below I certify that the information I have provided is true and accurate to the best of my knowledge, that I understand the nature of the group work and the associated risks, and that I agree to abide by program rules and the directives of clinical staff intended to promote safety and therapeutic benefit.

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