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The Mental Health Summit Consent Form



This Online Workshop is intended to provide information about overall wellness including various mental health services and support. The workshop is provided over the internet with the use of video and audio communications. The professionals facilitating this workshop are professionals in their own craft and do not offer this service as a substitute for medical care. 


All information provided is kept in strict confidentiality including but not limited to the names and shares of the attending members. 




As the online client, I hereby acknowledge and understand that

I will use a smartphone or webcam to attend the workshop.

I will use a quiet and private place free from distractions.

I will use a secure internet connection and not a public Wi-Fi connection.

I will do my best to arrive at the workshop on time.

I will not record the session without permission granted by the facilitators.

I will refrain from any harmful or hateful speech while in attendance of the workshop.  


The laws regarding privacy and personal data protection applies to my personal and

confidential information I willingly disclose during the online workshop. 


There are risks and consequences to online workshops, including, but not limited to, the

possibility, despite reasonable efforts on the part of the Facilitator, that the transmission

of my personal information could be disrupted or distorted by technical failures, the

transmission of my personal information could be interrupted by unauthorized persons,

and/or the electronic storage of my personal information could be unintentionally lost or

accessed by unauthorized persons.




• All information received by the facilitators from the client shall be held in strict confidence. This includes all and any information received verbally, electronically, in writing, or any other form of communication.

 • All such information shall remain in confidence after the workshop has ended.


Limits of Confidentiality 


Therapists keep information related to services provided confidential with the following noted exceptions: 

1. Files are demanded under a subpoena for the court 

2. The client reports current, active suicidal/homicidal intent 

3. The client and or facilitator are at risk of harm 

4. The client reports current (not historical) suspected abuse or neglect of a vulnerable person, in which case, only the relevant information is disclosed to the appropriate authority in the jurisdiction in which the client resides.




- I understand that these services are not offered as a substitute for medical care and are not intended to diagnose, treat or cure any mental health or medical conditions. I also understand that my therapist or coach is not acting as a medical professional.


- I understand and agree that I am fully responsible for my own well-being during and outside of the workshop, and subsequently, my choices and decisions.


- I have read and understand these terms and conditions as well as documentation relating to confidentiality and its legal exceptions.


- I understand that the use of technology is not always secure and accept the risks of confidentiality in the use of email, text, phone, video and other technologies.


- Therapist’s /Coach’s reserve the right to refuse or discontinue access to the workshop. For all international clients, all services are undertaken in accordance with the laws of the facilitator's own country and any disputes will be subject to the laws of that country.

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