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.

Retrospective Review Consent: We provide this community for you to enhance social and emotional support, and we would love to know whether this is helping. In the future, we may want to look back on all of this to see whether this has been of help you. When we look back at everything, we may want to capture summaries of all of the outcomes. These summaries may involve combinations that have your information included in a way that is mixed with everyone else’s and cannot identify you at all. If we look back at this work in this way in the future, we may call this “retrospective research” review. We may present and publish some of the combined and mixed results from these efforts, in a way that could not identify you. This research review would focus on understanding the effects on heart health, quality of life, and community, so that we can better tailor our services for the future. Through this research review, we may better understand these effects and determine which helpful efforts are beneficial in building healthy heart habits and enhancing community. The research review committee will understand and respect the privacy of each and every individual. We would present and publish the combined and mixed information from our findings without disclosing your individual personal information in a way that could identify you. By signing below, you consent to your information being used as part of this future research review. In the future, you can write us if you ever change your mind and would like your information removed from the combined and mixed results in our research review. 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.

This form will now end after this next message; submit the form, then we will immediately take you to the next crucial form! We can't wait to see you soon. :)