For ofc use:                

Date_________________

C/H__________________

AT___________________

To the best of my knoweldge, I verify that the above information is complete and accurate.

By checking I agree and submitting this form, you give permission for your child/teen to participate in the Kids' Grief and Healing program, which includes, but is not limited to groups at school, community locations, or Hospice of the Piedmont offices, individual support sessions, and camps.

I agree/do not agree to give permission to Hospice of the Piedmont's counselor(s) to share information via telephone, email, or in person regarding my child with his or her counselor and for my child to be seen by a Hospice of the Piedmont counselor, individually, or in a group at school.

I hereby consent to engaging in grief related telemental health counseling via Skype or Zoom. I understand that telemental health counseling may include the practice of grief support, consultation, and education using interactive audio, video, or data communications. 

I understand the following with respect to Telemental health services: 

• I understand that there are risks and consequences from distance counseling, including, but not limited to, the possibility, that despite reasonable efforts on the part of my child’s counselor, that: the transmission of confidential information could be disrupted or distorted by technical failures. These risks are offset by my child’s bereavement counselor’s use of Skype for Business or Zoom, HIPPA-compliant services which are encrypted for video telemental health communications. Further, the contents of my child’s therapist’s computer are encrypted.  
• In addition, I understand that telemental health services and care may not yield the same results nor be as effective as face to-face service.
• In emergencies, in the event of disruption of service, or for routine or administrative reasons, it may be necessary to communicate by other means, including telephone or secure email. I understand that SMS text messaging (e.g., through my cellular provider) and nonencrypted email are not secure and should not be used to convey confidential information.
• It is my responsibility to maintain privacy on the client end of communication. This includes not recording telemental health consultations without discussing the risks with my child’s counselor.
• I understand that there are potential risks and benefits associated with any form of counseling, and that despite my child’s efforts and the efforts of my child’s counselor, my child’s condition may not improve and in some cases may even get worse. I understand that my child may benefit from distance counseling, but that results cannot be guaranteed or assured.
• I acknowledge, however, that if my child may be facing an emergency situation that could result in harm to them or to another person; I am not to seek a telemental consultation for my child. Instead, I agree to seek care for my child immediately through our own local health care counselor or at the nearest hospital emergency department or by calling 911. 

I agree/do not agree to give permission for my child/teen to be photographed, videotaped, or interviewed and for his/her artwork to be photographer during the Kids' Grief and Healing program under supervision of staff. This material may be used for future publicity of the Kids' Grief and Healing program, including news media.

In consideration of the above-named child/teen being accepted by Hospice of the Piedmont to attend the Kids' Grief and Healing program:

I, for myself and on behalf of my child/teen, release and discharge Hospcie of the Piedmont, its staff, Board of Directors, Officers, Volunteers, from all claims, demands, actions and judgments, which I or my child/teen ever had or now has or may have against Hospice of the Piedmont for all personal injuries, either physical or emotional, known or unknown, and injury to property, real or personal, sustained by my child/teen's person or property during his or her participation in Kids' Grief and Healing camps or activities, including but not limited to, injury caused by negligence.

I agree to indemnify and hold harmless Hospice of the Piedmont, for any and all claims, demand, actions and judgments whatsoever of every name and nature, both in law and equity, which my child/teen ever had or now has or may have against Hospice of the Piedmont for all personal injuries, either physical or emotional, known or unknown, and injury to property, real or personal, sustained by my child/teen’s person or property during his or her attendance at Kids' Grief and Healing camps or activities, including but not limited to, injury caused by negligence.

I, the undersigned, have read this release and understand all of its items.  I understand that this content is valid for one (1) year from date of agreement, or the date my child ends his/her involvement with the Kids' Grief and Healing programs described herein, whichever is later.

TERMS AND CONDITIONS:  I give permission to staff of the Kids' Grief and Healing program to administer first aid to my child and authorize emergency transport to the nearest acute care facility.