Support Group Intake & Legal Waiver Form

Name

First NameLast Name

What pronouns do you use?

Date of birth

MonthDayYear

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

What draws you to this support space at this time?

This is a monthly, drop-in peer support group focused on mutual validation and community building, rather than structured group psychotherapy. Does this format align with what you are looking for?

Our community guidelines require confidentiality, respect for diverse theological/non-theological views, and giving everyone equal space to share. Are you comfortable committing to these agreements?

Time Zone

Participation Agreement & Non-Clinical Disclosure Statement

Please review the following carefully before signing. By signing below, you acknowledge and agree to the following terms:

1) Nature of the Group: This circle is a monthly peer support and psychoeducational space designed for community connection, mutual validation, and sharing lived experiences for adults (18+).

2) Not Professional Therapy: This group does not constitute psychological treatment, psychotherapy, counseling, or medical intervention. Participation in this group does not establish a clinical psychologist-patient relationship between you and the facilitator, even though the facilitator is a licensed psychologist.

3) Jurisdiction & Regulation: This group is organized and managed out of the State of Texas as a non-clinical community offering. It is not a healthcare service and is not subject to health insurance reimbursement; superbills will not be provided.

4) Limits of Confidentiality & Mandated Reporting: While all members agree to maintain strict privacy regarding who attends and what is shared, the facilitator is a mandated reporter in the State of Texas. If a participant expresses an imminent risk of serious harm to themselves or others, or discloses the abuse/neglect of a child, elderly person, or disabled adult, the facilitator is legally required to take steps to ensure safety, which may include contacting emergency services or relevant authorities.

5) Emergency Resources: This group cannot provide crisis management or emergency mental health services. If you are experiencing a mental health emergency, please contact your local crisis hotline, call/text 988 (in the US), or go to the nearest emergency room.

I have read, understood, and agree to the Participation Agreement above.*

Signature

Queer Muslim Support Group