Peer Support Registration

Client's Full Name

First NameLast Name

Clients DOB

Date

Participant is a member of:

Bellevue 21st Century (Hannah Hagedorn)Black and Latino Achievers (Jarod Roper)The Greater Cincinnati YMCANot affiliated with any of these groups

Client's Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Client's Email Address

example@example.com

Client's Mobile phone Number

Area CodePhone Number

Dear Participant (or Participant’s Parent/Guardian),

In order for you (or your child or ward, who is under the age of 18, hereinafter referred to as “Child”) to participate in Mindfully, LLC (“Mindfully”) Peer Support programs, we need your agreement and consent to the following. Please carefully read and sign this form. If you have any questions or would like further information, email info@mindfully.com.

By entering your Child’s contact information below, you give your permission for Mindfully to contact your Child directly via such means:

Child's email address

Child's Phone number

Parent/Guardian Name

First NameLast Name

Parent/Guardian Email

example@example.com

Parent/Guardian Phone Number

Area CodePhone Number

Parent/Guardian Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

If your Child is UNDER the age of 13, you must print this form, complete it, sign it, scan it, and email the signed form to info@mindfully.com.

Consent to Treat

In furtherance and consideration of my participation (or my Child’s participation) in Mindfully Peer Support programs, I agree as follows:

1. Participation:

I (or my Child) may participate in Mindfully Peer Support programs, including receiving communications, tools, and access to the Mindfully application, resources, website, website accounts, and connecting online with a Peer Support Specialist provided by Mindfully.
- Peer Support Specialists are trained are certified by state departments in areas such as behavioral health services or mental health and addiction services. For more details on Peer Support, see Attachment: What is Peer Support?
I understand the Mindfully website accounts provide access to Mindfully content, materials, and resources relating to Mindfully’s programs and activities.
I hereby give my permission for Mindfully to collect, use, and disclose my (or my Child’s) personal information for the purpose(s) described herein and in the Terms & Conditions and Privacy Policy.
I understand where to find the Terms & Conditions (viewable at: https://www.resolvhealth.com/terms-conditions) and Privacy Policy (viewable at: https://www.resolvhealth.com/privacy) for Mindfully, have reviewed and accept such Terms & Conditions and Privacy Policy.
I may revoke my consent at any time to refuse further collection and use of my (or my Child’s) information. Mindfully’s collection and use of my (or my Child’s) information will cease not more than five (5) business days after Mindfully’s receipt of my written revocation of consent. If I desire to revoke my consent, I will communicate my revocation of consent by scanning and emailing the following sentence to info@mindfully.com
- “I, {parentsName} , revoke my consent for my / my Child’s,{name5} (Insert Your Child’s Name), (Select One) participation in Mindfully programs and services.”

2. Services Provided

I understand that as a technology company, Mindfully does not provide professional support or coaching services. While Mindfully evaluates service satisfaction, Peer Support Specialists are responsible for delivering their service according to their certification and all applicable standards.
I understand Mindfully provides mental health resources, educational programs and support via Peer Support Specialists. The Mindfully website, resources, programs and Peer Support Specialists do NOT provide medical advice and are NOT intended to be a substitute for professional advice, diagnosis, or treatment. For an accurate diagnosis of a mental health disorder, I (or my Child) should seek an evaluation from a qualified mental health professional.
I understand Mindfully Peer Support Specialists are NOT licensed health care clinical providers, do NOT have a professional clinical background, and do NOT make diagnostic or clinical decisions.
I understand programs and services provided by Mindfully are for non-crisis, non-emergency situations. I (or my Child) must not use Mindfully for emergency medical needs, immediate or emerging crises. If I (or my Child) feel I am (or my Child is) experiencing a potentially life-threatening problem, I (or your Child) should call 9-1-1 or the Suicide Prevention Lifeline at 1-800-273-TALK(8255) or 9-8-8.

3. Confidentiality

I understand that while conversations between me (or my Child) and Peer Support Specialists are held confidential, there are times when confidentiality may be disclosed to protect myself (or my Child) or others, and to otherwise comply with applicable laws or regulations.
- Examples of when confidentiality may be disclosed include:
  - When there is disclosure or observation of abuse or child abuse
  - When a participant expresses the desire or plan to injure him/her/themself
  - When a participant expresses the desire or plan to harm others
  - When there is a need to discuss a participant's session content with a supervisor
- Under these or similar circumstances, information may be shared with the proper authorities.

4. Limitation of Liabiliy

I ACKNOWLEDGE AND UNDERSTAND THE FOLLOWING DISCLAIMER. MINDFULLY HEREBY DISCLAIMS ANY AND ALL LIABILITY FOR ANY SUPPORT, SERVICES, COACHING, OR ADVICE YOU (OR YOUR CHILD) RECEIVES FROM THE PEER SUPPORT SPECIALISTS, OR ANY INJURY OR HARM THAT MAY RESULT THEREFROM.
I HEREBY RELEASE AND HOLD HARMLESS MINDFULLY OF AND FROM ANY AND ALL CLAIMS, DAMAGES, AND LIABILITIES THAT HAS OR MAY ARISE FROM ANY SUPPORT, SERVICES, COACHING, OR ADVICE I (OR MY CHILD) RECEIVE FROM MINDFULLY.

I CERTIFY THAT I AM 18 YEARS OF AGE OR OLDER AND THAT I HAVE READ, FULLY UNDERSTAND AND AGREE TO THE TERMS OF THIS AGREEMENT, AND I SIGN IT VOLUNTARILY WITH FULL KNOWLEDGE OF ITS SIGNIFICANCE.

I CERTIFY THAT I AM A PARENT OR GUARDIAN OF THE ABOVE-NAMED CHILD AND THAT I AM SIGNING ON BEHALF OF MY CHILD. I CERTIFY THAT I AM 18 YEARS OF AGE OR OLDER AND I HAVE READ, FULLY UNDERSTAND AND AGREE TO THE TERMS OF THIS AGREEMENT, AND, ON MY BEHALF AND ON BEHALF OF MY CHILD I SIGN IT VOLUNTARILY WITH FULL KNOWLEDGE OF ITS SIGNIFICANCE.

Signature

This is the end of the Consent Form. Thank you.

What is Peer Support?
Peer Support Specialists (Peers) "offer emotional support, share knowledge, teach skills, provide practical assistance, and connect people with resources, opportunities, communities of support, and other people"1. Peers offer their unique lived experience with mental health conditions to provide support focused on advocacy, education, mentoring, and motivation.

Registration

Consent Form for Peer Support Programs