Consent & Waiver Form

Purpose and Description:

The mental health process groups aim to provide a supportive and confidential environment for students to explore and discuss various mental health-related topics. The group sessions are intended to encourage mutual support, self-reflection, support, and personal growth. Participants will engage in discussions, activities, and exercises designed to promote mental and emotional wellness, coping strategies, and interpersonal skills.

Facilitator:

Letitia Laurien, LCSW, QS

Email: info@letitialaurien.com

Contact#: (772) 208-8773

 Location:

All groups are being held on the premises of Lindsay School for the Arts during the school day. 

Potential Benefits:

Increased self-awareness & Emotional Intelligence
Enhanced coping skills and stress management techniques
Support from peers facing similar challenges
Development of communication and interpersonal skills

Potential Risks:

Discussions may evoke strong emotions or discomfort.
Confidentiality cannot be guaranteed if a participant discloses intent to harm themselves or others.
While the group aims to provide support, it is not a substitute for individual therapy. (contact Letitia Laurien when you feel individual therapy is needed) 

Voluntary Participation:

Participation in the mental health process group is entirely voluntary. The student has the right to withdraw from the group at any time without consequence or explanation.

By allowing the student to participate in this type of programming you agree to the following terms and conditions:

A. Nature of the Process Groups

1. The information presented during groups, including ideas, suggestions, techniques, exercises, initiations, processes, activities, energetic activations, empowerments, downloads, instructions, and other materials (collectively the “Materials”), is educational in nature and is provided only as general information and is not medical advice.
2. You understand the groups are experiential in nature and focuses solely on personal growth, mental, and spiritual transformation and is not to be considered sole treatment for any physical, emotional, or mental disorder. You agree to consult with a health care providera or a mental health provider for any specific medical, emotional, or psychological problems or issues. 
3. Understand that LooseLeaf Holistic Wellness, LLC makes no warranty, guarantee, or prediction that the student will experience any particular state of awareness or consciousness during or after the groups, nor does it make any representation that you will experience any particular outcome on an issue. Due to the fact that this type of programming includes group processes in which one may voluntarily reveal personal information, understand that you waive rights of privacy and confidentiality. You acknowledge and agree that anything and everything discussed with the Facilitator or any participant is merely a perspective for to consider.
4. You further understand that participation in the groups is not intended to create nor does it establish a client-practitioner relationship or any other type of therapeutic or professional relationship between the student and Letitia Laurien.
5. Please be advised that by participating in the group, emotional, physical, or spiritual sensations may surface which could be perceived as negative side effects and possibly cause psychological and/or physical discomfort. If distressing reactions are experienced by participating in the group, the student can ask for help from Letitia Laurien, or seek out individual services from a mental health provider.

B. Waiver of Liability

1. By signing this consent form, you are stating that the student is competent and able to understand the nature and consequences of participating in the groups, and that you are an adult under the laws of the State of your residence who can give consent for this student. 
2. Understand that the students participation in the group is strictly voluntary, at their own risk, and that they freely choose to participate. Since the groups are experiential and the extent of the groups risks and benefits are not fully known, you agree to assume and accept full and complete responsibility for any known and unknown risks associated with the students participation in the group, including any physical injury, psychological or emotional effects, death, loss, or property damage.
3. You agree to release LooseLeaf Holistic Wellness LLC, Letitia Laurien, the Facilitators, employees, volunteers, and any independent contractors from any liability resulting from the students participation in the group. Specifically, you and the student agree to fully release, indemnify, hold harmless and defend the LooseLeaf Holistic Wellness LLC, Letitia Laurien, the Facilitators, employees, volunteers, and any independent contractors, from any and all claims or liability, and for any damage or injury, including but not limited to, financial, personal, emotional, psychological, medical, or otherwise, which you may incur arising at any time as a result of your voluntary decision to participate in the groups.
4. In the event of an accident, injury or sickness, you give permission to LooseLeaf Holistic Wellness, LLC, Letitia Laurien, the Teachers, employees, volunteers, and any independent contractors to seek medical attention and/or authorize emergency medical treatment if necessary. LooseLeaf Holistic Wellness, LLC will first attempt to communicate with the guardian as an authorized emergency contact before seeking medical treatment for the student, unless it is not feasible or practical. LooseLeaf Holistic Wellness, LLC, Letitia Laurien, the Facilitators, employees, volunteers, and any independent contractors will not be held liable for any accident, injury, sickness, death, loss, or property damage that might arise out of or in connection with such authorized emergency medical treatment.
5. You further agree to hold harmless LooseLeaf Holistic Wellness LLC, Letitia Laurien, the Facilitators, employees, volunteers, and any independent contractors from any damages or costs, including Court and attorney’s fees, which may be incurred due to the students participation in the group.
6. You agree and understand that the student may be photographed and/or recorded and that LooseLeaf Holistic Wellness, LLC and Letitia Laurien shall have all rights in and to such film, photographs and/or recording, including the copyright therein. The copyright shall include, but not be limited to, the right to use, re-use, publish, and re-publish and otherwise reproduce, modify, and display any such film, photograph and/or recording for educational and promotional purposes, including without limitation, audiotapes, audio CDs, DVDs, websites, video, or film or any other form of recorded images. You grant LooseLeaf Holistic Wellness, LLC and Letitia Laurien the right, without compensation to you, to film, photograph and/or record you while participating in the group and you waive any right which you now have or may have hereafter in any such film, photograph and/or recording. You agree to not record by audio, video, photographic or any other means, any portion of the group.
7. Any and all matters in dispute between the parties to this Agreement, whether arising from or relating to the Agreement itself, or arising from alleged extra-contractual facts prior to, during, or subsequent to the Agreement, including, without limitation, fraud, misrepresentation, negligence or any other alleged tort or violation of the contract, shall be governed by, construed, and enforced in accordance with the laws of the state that you, as the participant, reside in, and the state that any facilitator with LooseLeaf Holistic Wellness, LLC resides in without regard to conflicts of law doctrines and regardless of the legal theory upon which such matter is asserted.
8. If any portion of this Agreement is held to be invalid, it is agreed that the balance of the Agreement shall continue in full force and affect. This Agreement shall be binding upon you and your heirs, family, legal representative, successors, and assigns. This Agreement constitutes the entire and final agreement between the parties and supersedes any prior oral or written agreements, discussions or understandings. This Agreement may not be modified in any respect except in writing describing the modification and signed by both parties.
9. By signing below, you acknowledge that you have carefully and completely read and fully understand all aspects of this Agreement and you agree to all of the terms and conditions stated herein. You also give consent for the student to participate in all services related to the mental health and psychoeducational groups that will be conducted for Linsday School for the Arts. 

As the parent/guardian of the student named above, I have read and understood the information provided about the mental health process group. I consent to my child's participation in the group sessions.