COVID 19 Healthcare Worker Support Services Consent

Harmonious Mind, LLC

Address: 5189 W Woodmill Dr., Wilmington DE 19808. Website: www.HarmoniousMind.com

Tel: 302.633.6001 Fax: 302.295.6289 SMS/Text: 302.565.4818 Email: Support@HarmoniousMind.com

Full Name

Date of Birth

Home Address

E-mail Address

Phone Number

Emergency Contact-Name and Relation

Emergency Contact No.

Employer Name and Address

Enter your Job Position and Description:

How long have you been impacted by the stress/symptoms as a result of COVID 19 exposure?

What setting of therapy sessions are you interested in?

Individual

Group

Both

I confirm that I have the legal right to give this consent...

Enter Initials

I hereby give Consent to Harmonious Mind for the following;

Covid-19 Support Services

I give permission to use Text and e-mail for communication

I hereby release, waive, covenant not to sue, and agree to hold harmless for any and all purposes sponsor, Harmonious Mind LLC, and its members, officers, agents, volunteers, or employees (“RELEASEES” or “INDEMNITEES”) from any and all liabilities, claims, demands, injuries (including death), or damages, including court costs and attorney’s fees and expenses, that may be sustained by me while participating in this activity, while traveling to and from the activity, or while on the premises owned, leased, or controlled by RELEASEES, including injuries sustained as a result of the sole, joint, or concurrent negligence, negligence per se, statutory fault, or strict liability of RELEASEES.

Enter Full Name, as Signature

Date Signed

Upload copy of Driver's License. Front and Back.

NOTE: Treatment is not conditioned by having to sign this consent. This information has been disclosed to the above-named recipient from records protected under Federal privacy regulations within the Health Insurance Portability and Accountability Act (HIPAA), 45 CFR parts 160 & 164. The information specified above will be disclosed pursuant to this authorization, and the recipient of the information may re-disclose the information, which may no longer be protected by the HIPAA privacy law. This consent is subject to revocation at any time except to the extent that action has been taken in reliance thereon. To revoke this consent, the request must be done in writing to: Support Staff or your therapist at Woodmill Corporate Center, Suite 30, Wilmington, DE 19808. If not previously revoked, this consent expires on date recorded below.

Your information will be encrypted.