Unmasking ADHD Alumni Consent Form

Unmasking YYJ Consent Form - ALUMNI

Thank you for your continued interest in participating in group! We can't wait to have you join us again. Please take a moment to fill out our online intake consent form before the first session. All information is kept completely confidential. Thank you!

This form will:

1. gather some basic information for us to keep on file

2. go over informed consent

3. review payment options.

Please reach out to us at unmaskingyyj@gmail.com if you have any questions.

First name

Last name

Phone

Birthday

Year

Month

Day

Address

Yes, I would like to be notified via email of new things happening with Unmasking YYJ!

Payment Options

In our commitment for accessibility and community care, we've provided a tiered pricing system for our group. We also want to make payment for group accessible for all, so we are offering a couple options. Please select which payment method works best for you.

Payment Method

Please select which payment method you would like to use for your payment(s) for group.

Consents

Informed Consent

Our role as facilitators is to provide a space & offer opportunities for psychoeducation, resource sharing, & connection amongst members. We will work in collaboration with you to build an environment that feels supportive and enriching.

If you are dissatisfied with the group experience at any time, please do not hesitate to contact us and share your concerns.

Your privacy is important to us. Any of your information provided will be stored securely via Wix booking system.

Confidentiality

As a participant in this group, your confidentiality is of utmost importance. As Registered Clinical Counsellors, it is our responsibility to maintain this. Confidentiality will only be broken if:

- We have reason to believe a child under 19 years of age has been, or is likely to be, physically harmed, sexually abused or exploited, or is otherwise in need of protection.

- We are concerned that a participant is likely to harm themselves or someone else.

Payment & Cancellation

I understand the cost for Unmasking, and the payment options. I have selected which tier, option, and method work best for me.

If for any reason we have to cancel this group, you will be issued a full refund.

Full payment for group is required whether you are able to attend all sessions or miss some. Refunds will not be issued for any sessions you cannot attend.

Signature

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By signing, I am agreeing to the above information.