Non-Disclosure Agreement

In consideration of the opportunity to observe the performance of personnel at K&G Counseling and Consulting (“shadow”) as part of an observation program or interview, I agree to the following:

1. I understand that patients must consent to my presence.
2. I agree to maintain and protect the absolute confidentiality of the names of the patients and any other patient identifying information, as well as all information relating to the condition, diagnosis and treatment of any patient.
3. I understand that this is an observation only experience. I agree not to provide care of any kind to any patient or to write on any patient’s medical record.
4. I understand that K&G Counseling and Consulting will not assume or provide any type of insurance coverage, including malpractice insurance coverage, for me while I am on hospital premises.
5. I voluntarily assume all risks associated with my presence as an observer.
6. I understand that K&G Counseling and Consulting reserves the right to terminate the observation experience at any time.

I hereby release K&G Counseling and Consulting, its staff, employees, agents and representatives from any liability, injury or damages caused by or arising from or in connection with my presence as an observer in the office.