CONSENT TO PROVIDE SERVICES AND LIABILITY WAVIER

Participants Email that will be used to verify this form:

 Services provided by Adapt 2 Healing LLC Digital Peer / Peer Support/ Family Support


Location of Peer Support Provider: VIRGINIA                                                                                                                             

  1. Purpose:  The purpose of this form is to obtain your consent to participate in a Digital Peer Support visit in connection with the following service(s) and/or procedure(s):  Peer Support/ Family Support Sessions One on one/ Group Sessions/ and other Services Provided Digitally/ Virtually by Adapt 2 Healing LLC Providers.

                                                                                                      

  • Scope and Limitations:  Digital Peer Support and Services visits are not Fulfill all Mental Health / Physical Health needs.   Your Provider will support you in determining which Digital Support service(s) and/or processes (s) are appropriate for you.  

  • Confidentiality and Security:  All information given at your Digital Support visit will be kept and protected in full compliance with federal and state privacy laws.  Efforts, including not limited to the following: training staff to the proper procedures and process for handling Participants information, using secured and encrypted, platforms as available including cloud-based, updating/patching of software as updates are available, and encryption and password-protected data drives and folders) have been made to keep your information confidential.  No system is flawless.  You (the participant) agree that technological failures may occur.  Some or all of your information may be electronically lost or breached.  The Digital Peer visit may also be interrupted or canceled due to technical failure(s).

  •  Medical Records:  All federal and state laws about access to your medical records apply to Digital Peer Support.  You may request access to your records.  

  • Rights:  You may opt-out of the Digital Peer Support visit at any time.  This will not change your right to future care or health benefits.  

  • Risks and Consequences:  You have been advised of the potential risks and benefits of Digital Peer Support visits.  You have had a chance to ask questions about the Digital Peer Support visit.  You have received satisfactory answers to your questions.  You are in understanding that Adapt 2 Healing LLC and its members are not and will not be or made to be liable at all including events and or outcomes as it pertains to you and others receiving and not receiving services.  

By agreeing to this form checking the box and signing, you agree to the above terms, and you (the Participant) agree that you understand the information in this form.