Grief Support Group Consent Form

New Hope for Kid’s Grief Support Group Consent, Policies, & Agreement

Hello Families,

Thank you for reaching out to New Hope for Kids for support on your grief journey. We look forward to providing grief support to your family through New Hope for Kids’ (NHFK) Grief Support Group Sessions, both in-person and
utilizing Zoom. The following information will provide you with what you can expect regarding your participation both in-person and virtually.

PLEASE READ ALL OF THE FOLLOWING GUIDELINES THEN FILL IN ALL REQUESTED INFORMATION.

Benefits & Limitations: Some Grief Program services are provided by technology including but not limited to video, phone, text, apps and email. Meeting virtually allows for continuity, additional schedule flexibility and extension of grief support services.

It is important to note that there are limitations that can affect the quality of virtual session(s). These limitations include but are not limited to the following:
- If you choose to refrain from using video, your peers and the group leader cannot see you, your body language, or your non-verbal reactions to what we are discussing.
- Due to technology limitations, the participants and or the adult counselors/ facilitators may not hear all of what you are saying and may need to ask you to repeat things.
- Technology might fail before or during the Virtual Support Group.
Although every effort is made to reduce confidentiality breaches, breaches may occur for various reasons.

Getting Set Up/Logistics for Virtual groups and meetings:

Virtual schedule and links will be sent via email and/or Remind app to the contact information provided for the parent/legal guardian. (PLEASE CHECK BOTH WEEKLY FOR UPDATES)
NHFK grief program staff and facilitators will be conducting video sessions from a private location where the staff member or facilitator is the only person in the room.
As a participant, you will want to be in a private location where you can speak openly without being overheard or interrupted by others to protect your own confidentiality. If you choose to be in a place where there are non-group participants or other people who can hear you, NHFK cannot be responsible for protecting your confidentiality.
We encourage you to make every effort to protect your confidentiality. We request that group participants wear a headset to maintain confidentiality and to increase the sound quality of the group.

Recording of Sessions Not Permitted: Please note that audio and/or video recordings, screenshots, taking pictures, etc., of any participant, and any portion of group activities during any session or meeting, is not permitted and are grounds for termination of your right to participate in NHFK Virtual Grief Support Group. Even with this rule, NHFK cannot guarantee the privacy or confidentiality of conversations held via phone, as phone conversations can be intercepted either accidentally or intentionally.

NHFK will periodically record sessions and take photos during virtual grief support groups to use for grief program awareness materials, both in print and online, including NHFK social media platforms. We will make participants aware prior to recording in the event that you would like to turn off your audio and/or video at that time.

Connection Loss During Phone and/or Video Sessions: If you lose phone and/or video connection during your group session, click the Zoom link again to take you back to your group session.

Crisis: If a situation occurs during a NHFK Virtual Group where you are disconnected while talking, and you are in a crisis, you agree to call 911, go to your local emergency room immediately or contact the National Suicide Hotline at 800-784-2433.

If concerns about your safety, or the safety of others, are developed by NHFK staff and/or group facilitators due to your interaction with the same or participation in any NHFK Virtual Group, such NHK staff and/or group facilitators may (or shall, as required by applicable law), notwithstanding any confidentiality obligation, inform law enforcement or other emergency responders (if located in the same county or emergency services in the area you are located at the time of the call) and/or your emergency contact of the facts and circumstances giving rise to such concerns. Please note that everything in the section titled “Your Rights to Privacy and Exceptions to Privacy”, contained in the NHFK Family Information Packet, applies during phone/video sessions.

Parent/Guardian’s Name:*
First Last
Cell Phone:*
Emergency Contact*
First Last
Relationship*
Phone*
Please list the address from which you are located during the time of your session.*
Street Address City State / Province / Region ZIP / Postal Code
How many children are you agreeing will follow the above guidelines and allow to participate in NHFK Virtual & In-Person Grief Support Groups?*
Child 1*
First Last
Date of Birth*
MM slash DD slash YYYY
Child 2*
First Last
Date of Birth*
MM slash DD slash YYYY
Child 3*
First Last
Date of Birth*
MM slash DD slash YYYY
Child 4*
First Last
Date of Birth*
MM slash DD slash YYYY
Child 5*
First Last
Date of Birth*
MM slash DD slash YYYY
Child 6*
First Last
Date of Birth*
MM slash DD slash YYYY
How many additional adults are you agreeing will follow the above guidelines and allow to participate in NHFK Virtual & In-Person Grief Support Groups?*
Adult 2 Name:*
First Last
Relationship to Child(ren):*
Cell Phone:*
Address: (If different than Parent/Legal Guardian)
Street Address City State ZIP Code
Emergency Contact: (If different than Parent/Legal Guardian)
First Last
Relationship to Adult 2:
Cell Phone:
Adult 3 Name:*
First Last
Relationship to Child(ren):*
Cell Phone:*
Address: (If different than Parent/Legal Guardian)
Street Address City State ZIP Code
Emergency Contact: (If different than Parent/Legal Guardian)
First Last
Relationship to Adult 3:
Cell Phone:
By checking this box, you give consent for you, all additional adults and children listed to be recorded and/or photographed, and for those videos and/or photos to be used for NHFK grief program awareness materials.
*
Release of Liability: I, my children and all participating adults, unconditionally release and discharge NHFK, its affiliates, agents, employees and our peer group counselor/facilitators from any liability in connection with our participation in the NHFK Virtual & In-Person Grief Support Groups.
*
I, my children and all participating adults, agree that we have read and understand all of the above sections of NHFK Grief Support Group Consent Form. We agree that we also understand the limitations associated with participating in NHFK Grief Support Group sessions and consent to attend groups under the terms described in this document.