I agree to respect the confidentiality of all information shared/obtained while participating in Heart Beach Garden. I also expect that the information I provide will be held in confidence by group participants and moderators, if applicable.
I recognize that information shared by participants or moderators will be held in confidence except in situations when mandated reporting is required:
- When the client threatens bodily injury to another or is suicidal.
- When there is reasonable suspicion that abuse or neglect toward a child, elder or dependent adult has or will occur.
- When ordered by a court.
Any information shared in this public forum is considered public information and I understand that Heart Beach Garden and My Heart Spark P.C., including their current and former affiliated or related corporate entities, are not liable if any participant shares that information without consent.
In addition, I agree to use acceptable language with no profanity, curse words, or stories or phrases that may be considered obscene or inappropriate.
I confirm that I have no limitations to participation. Communication among participants can occur using my phone, laptop, tablet, or other appropriate device. I can view others safely on my device or communicate with others via audio only.
I recognize that I am personally liable for ensuring my safety and secure communication. I understand and agree that I or any other individual or entity can and will not hold, consider, or determine Heart Beach Garden and My Heart Spark P.C., including their current and former affiliated or related corporate entities, liable or responsible in whole or in part for any injuries or damage physically, emotionally, socially, or otherwise that occur in relation to my participation.
I attest that my electronic signature on this form is to have the same legally binding effect as my traditional handwritten signature.
I am 18 years of age or older, and I am authorized to sign this form on my own behalf.