Release of Liability Form Agreement

Support Circle

Release of Liability Form Agreement

I fully understand and agree to the following:

National Deaf Therapy will provide Support Circle lead by community member. It is a supportive meeting place for anyone with mutual experiences to be able to connect with and share ideas with others on living with the selected topic for support circle I am joining. We discuss ways to deal with unknowns in relationships, friendships, and career and life direction in regards to the topic.

  1. Confidentiality: Everything discussed in the group is confidential. Individual identifying information is not shared outside the group.  Group members understand the importance of confidentiality and agree to keep information and experiences shared in groups in the strictest confidence.  When violating this confidentiality, group member will be asked to leave and referred to other resources.

  2. Sharing: Group members are encouraged to share their skills, insight, strengths and hopes, and to recognize that everyone in group has expertise in dealing with the topic. Individual should not be named/identified.

  3. Sharing Spaces: If there is a concern of safety regarding whom you might enter space with…

    If there is a possibility that a person who caused harm to you cross paths in same space, you may contact and share your concerns and ask with specifics in how we can best support you and maintain your safety.

  4. Listening: Group members are courteous to each other at all times. This includes not interrupting or talking while someone else is talking and listening attentively when another person is speaking.

  5. Healing Space: If we notice disruptive, threatening, violent, and/or inappropriate behaviors or comments we will ask you to leave. We will remember that people in the group may differ in cultural background, sexual orientation, and/or gender identity or gender expression and will be careful about making insensitive or careless remarks. Perpetuating non-inclusive use of language such as stereotyping or demeaning people based on personal characteristics (including, but not limited to, gender, gender expression, race, ethnicity, economic background, ability/disability status, religion, sexual orientation; you will be held accountable and possibly asked to leave.

  6. Respect: Group members are respectful of each other’s feelings, views and concerns at all times. Group members are respectful of everyone’s right to participate equally in the discussion or not to participate, if that is their wish. Demonstrate respect cultural differences and diversity of views. No one is better than another – we are all equal with different perspectives and lenses.

  7. Responsibility: Group members take responsibility for the success of this support group by maintaining their focus on the issues and coping strategies specific to the group and the topic being discussed.  Group members are encouraged to use ‘I’ statements so that everyone speaks in the first person. Group members are responsible for their own wellbeing and are encouraged to look after themselves and seek support if they are upset before, during or after group.

  8. Technology: Support circle participation requires a reliable internet connection and tablet, laptop or desktop computer with a webcam. Mobile phones not compatible. Your space during the support circle must be confidential and it is required to create a space that is low vision accessible such as wearing solid contrast color tee shirt and a solid contrast backdrop.

  9. Adults Over 18 Years of Age: The support circle participant must be 18 years or over. This form must be completed by a person aged 18 years or over. This foregoing electronic agreement, have been made and that I am at least eighteen (18) years old.

Important Note: Please be aware that National Deaf Therapy is not a crisis center and do not use National Deaf Therapy’s Support Circle to receive immediate support. If you are experiencing suicidal, self-harm, or are feeling unsafe, please call 1-800-273-8255 (National Suicide Helpline), a free 24-hour hotline available to anyone in suicidal crisis or emotional distress; or text Crisis Text Line: Text START to 741-741.  You can also dial 911 or visit your local emergency room if you feel as though you are in an unsafe crisis.

My e-signature indicates that I have read this Release of Liability in its entirety, understand my rights and responsibilities, and have discussed any questions or concerns I have regarding this agreement with National Deaf Therapy administration team.

In signing this form, I understand and consent to National Deaf Therapy’s Support Circle: Release of Liability Form.