Pain Support Group Participation Agreement

Introduction
This agreement outlines the terms and conditions for participation in the Chronic Pain Support Group organized by Manhattan Pain Medicine. By signing this document, you acknowledge that you have read, understood, and agree to the following:

1. Consent to Participate

I voluntarily consent to participate in the Chronic Pain Support Group organized by Manhattan Pain Medicine. I understand that:

• The group meets monthly, online, to share experiences and learn from guest speakers.
• The purpose of the group is to provide a safe and supportive space for individuals living with chronic pain.
• Participation is voluntary and free of charge, with no guarantee of continued service.

2. Nature of the Group

• This group does not constitute healthcare delivery and does not establish a doctor-patient or therapeutic relationship.
• The group is not a substitute for professional medical advice, diagnosis, or treatment.
• Any information shared by guest speakers is for educational purposes only and should not be considered medical advice.
• I will consult my own healthcare provider for any medical concerns or treatment decisions.

3. Confidentiality Agreement

I agree to maintain the confidentiality of all information shared within the group:

• I will not disclose identifying information about any group members, including names, physical descriptions, or personal details.
• I may discuss my own experiences but will not share specific details about other participants.
• Group leaders will maintain confidentiality as required by law; however, communications among members are not legally protected, and absolute confidentiality cannot be guaranteed.
• I consent to the collection and use of any disclosed personal information in accordance with HIPAA regulations.

4. Acknowledgment of Risk and Release of Liability

I acknowledge and agree that:

• Manhattan Pain Medicine, its employees, and volunteers are not liable for any injuries, damages, or losses resulting from my participation.
• Facilitators, organizers, and affiliated individuals or organizations are released from liability for any claims or damages, including emotional distress.
• I assume all risks associated with participating in this group.

5. Virtual Participation and Privacy

• The Support Group may be held in person or virtually.
• Virtual meetings may involve security and privacy risks beyond the control of organizers.
• I waive any claims against facilitators for privacy breaches that may occur due to virtual participation.

6. Emergency Contact Authorization

In case of an emergency, I authorize the group facilitators or organizers to contact the emergency contact listed above.

7. Termination of Participation

I understand that Manhattan Pain Medicine reserves the right to terminate my participation if:

• My behavior is disruptive,
• I violate the confidentiality agreement, or
• My actions are otherwise deemed inappropriate for the group setting.

8. Acknowledgment and Agreement

By signing below, I confirm that:

• I have carefully read and understand this Agreement.
• I have had the opportunity to ask questions.
• My participation in the group is contingent upon my acceptance of these terms.