Participant Confidentiality & Privacy Acknowledgment
Please review and acknowledge the following confidentiality and privacy terms related to your participation.
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Acknowledgment Text
I understand that all personal information shared verbally or in writing with the Retreat Organizers will be kept confidential and used solely for the purpose of delivering non-clinical harm reduction, integration, and natural medicine support services.
I acknowledge
My information will be stored securely and only accessible to those directly involved in providing services to me.
I acknowledge
My confidentiality may be legally breached only under the following circumstances: If I disclose a serious and imminent risk of harm to myself or others; If I disclose abuse or neglect of a child, elder, or dependent adult; If records are subpoenaed by a court of law; If I provide written consent for specific information to be shared.
I acknowledge
I may request access to review or receive a copy of my personal records at any time.
I acknowledge
I agree to maintain the confidentiality of anything shared by others during group settings (e.g., group integration sessions).
I acknowledge
I understand that digital communication (email, video conferencing, messaging) may carry inherent privacy risks, and I accept those risks when choosing to engage in these formats.
I acknowledge
Participant Name
*
Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty: