Northwestern HDSA Center of Excellence online group forum

Date Date / MM / DD YYYY
Name Name First Last
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone - ### - ### ####
Email
Please Read and Review Consent and Terms of Use
Consent and Release Northwestern Memorial Healthcare Huntington's Disease support group participation As a group participant, I hereby consent to participation in a Northwestern Memorial HealthCare (“NMHC”) HDSA Center of Excellence support group. NMHC will provide Group sessions at no cost to Participants. The Group facilitator is currently designated as Emily Zivin, LCSW. Group facilitator may change depending on availability. Groups are subject to have co-facilitators and guest speakers. I understand that these group sessions are for social support only and that none of the information I disclose will be shared with my healthcare providers for healthcare treatment purposes. I further understand that, in the event that I require medical attention, it is my responsibility to directly contact my physician’s office (or, in the event that I need immediate medical assistance, to call 911). I understand the group facilitator will instruct other participants to keep information shared by other participants confidential; however, I understand that other participants may not keep my information confidential. I further understand that in the event that group facilitator is concerned that I may engage in self harm or cause harm to others, group facilitator may be obligated to disclose this information to appropriate authorities. I understand that participation in group sessions is voluntary, and I hereby consent to my participation in the group sessions. I acknowledge and agree that my participation in the group sessions may involve some risk of injury or reputational harm and that I have read and agreed to the “Rules of the Road” for participation that are attached. I assume full responsibility for all risks related to my participation. Release and Waiver of Liability. I, as participant if 18 years or older, hereby release NMHC, its subsidiaries and affiliated entities, and their respective past, present, and future directors, officers, employees, and agents from any liability, claims, demands or causes of action for any injury or reputational harm arising out of or connected with my participation in the group sessions. By signing this document below, I hereby confirm that I have read fully and understand the above statements, including the Release and Waiver of Liability and the “Rules of the Road”. Terms of Use (“Rules of the Road”) By participating in an online support group facilitated by NMHC, please note you are agreeing to the following: NMHC encourages you to participate in open discussions, share your experiences, ask questions and inquire about NMHC through our public social media communities, including online support groups (e.g., Teams, Facebook, Twitter, YouTube, LinkedIn, Blog). We reserve the right to monitor our social media communities to ensure any shared content is appropriate. Please note that any information available through our social media communities, including online support groups, should not be considered medical advice and does not replace a direct consultation with a health care professional. Please recognize that anything shared online is available to the public. Please use caution when sharing medical information on any of the NMHC’s social media communities, including online support groups, and never disclose personal identifiable information (including but not limited to: your location, medical record number, financial information, other private information). Please remember that you are responsible for the content you share and all activity that occurs under your social media account or in any online support group. You agree to the following while using or engaging with NMHC’s social media communities, including online support groups. • You agree to not misrepresent yourself or take on the identity of someone else. • You agree to not use any of the NMHC social communities, including online support groups, for personal attacks, defamation, harassment, spam, offensive content, aggressive behavior, or illegal activities. • You agree not to share content that is illegal, obscene, defamatory, threatening, unlawful, disruptive, profane, harassing or abusive. NMHC reserves the right to monitor, prohibit, restrict, block, suspend, terminate, delete or discontinue your access to any social community at any time, including online support groups, without notice in its sole discretion. Opinions and views expressed by individuals on the NMHC social media communities, including online support groups, are not necessarily those of NMHC, its employees, staff or board members. Please note if you are a NMHC employee you must adhere to the NMHC Social Media Policy available internally.
Please provide a contact who can be reached with respect to comments made or behavior exhibited on the group sessions in violation of the Rules of the Road (see Consent). Please provide name and number.
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.