ConneXions Group Class Step 1 of 7 14% Date* Date Format: MM slash DD slash YYYY Social Security No.*Name*DOB* Date Format: MM slash DD slash YYYY Age*Address* Street Address City State / Province / Region ZIP / Postal Code Email* Phone Numbers : Daytime*Work*Other*Occupation*Highest Level of Education* Emergency Contact*Phone(s)*Address* Street Address City State / Province / Region ZIP / Postal Code Relationship* Family Physician*Phone Number*Referred by*Address* Street Address City State / Province / Region ZIP / Postal Code Will this person need to be contacted?* Yes No May we send information about this program?* Yes No Psychiatrist/Counselor*Phone number*Address* Street Address City State / Province / Region ZIP / Postal Code Referred by*Will this person need to be contacted?* Yes No May we send information about this program?* Yes No With Whom Do You Now Live? List People and Relationship(s)*NameRelationship I give Connections Classroom permission to call my family doctor/therapist/EAP as necessaryPrint Name of Group Member*Date* Date Format: MM slash DD slash YYYY Signature* AGREEMENT FOR CONNEXIONS CLASSROOM RECOVERY GROUPI,Name** agree to the following arrangement with Connexions Classroom.I will pay my tuition of* Yes I will pay my tuition oftuition amount**per week one month in advance in order to secure my place in the group. attend group* Yes I commit to attend group for a minimum three (3) months continuously. I will pay for my first 3 months of group tuition up-front before attending.* Yes My payment will be charged to a credit card I provide prior to my first group every month.I am expected to pay for all groups* Yes I understand that, like tuition, I am expected to pay for all groups, whether or not I am present. Extenuating circumstances will be considered on an individual basis, according to the urgency of the circumstances.I will pay for all collections fees* Yes I will pay for all collections fees or attorney fees incurred should the need arise to send my account to a third party for collection.I may not discuss any group issue* Yes I understand I may not discuss any group issue with any other party, including family members or partners.I must be consistently present at group* Yes I understand I must be consistently present at group, that I must not break into subgroups (i.e. dating other members, or meeting with other members outside of the group), and should not be chronically late.two consecutive unexcused absences* Yes I understand two consecutive unexcused absences, without prior discussion with the coach and group, will result in expulsion from the group. I realize I may reapply to the same group if I am willing to commit to function as part of the group.group will typically be rescheduled* Yes I realize group will typically be rescheduled if the group meeting falls on a major holiday, and I will plan on attending at the designated time.law may require my coach* Yes I understand the law may require my coach to notify authorities if I reveal I am abusing children or have express intent to harm myself or other people.if I share information* Yes I understand that if I share information, outside of the group, about an individual in the group, that individual may have grounds to bring legal action against me. I agree to hold information I received from group members confidential and that I will not share any information with anyone who is outside of my group or with other group members outside of the group.I give permission for my statement* Yes Upon initialing this box, I give permission for my statement and any other correspondence from the Connexions Coaching staff to be received through email, fax, texting, and any other form of electronic communication.I am releasing confidentiality* Yes Upon initialing and signing this form below, I am releasing confidentiality to the person I have indicated below. I am requesting that my statement and any correspondence connected to paying for this bill incurred, will be communicated with them to the extent of the bill being paid.Name of third party for paying bill:Name of third party for paying bill:**no sexual contact* Yes I agree to have no sexual contact with other group members. Exceptions apply only to those whose legal spouses are also participating in the group. I understand if I violate this condition, I will be required to discontinue participation in the group.abstinence from all addictions* Yes I commit to abstinence from all addictions including fantasy and lusting.my recovery is my primary responsibility* Yes I understand my recovery is my primary responsibility. group coaching is often intense* Yes I understand group coaching is often intense and uncomfortable. I commit to being responsible for my own emotions. I hold the facility, group and coach harmless for any discomfort in the group setting.Signature of Group member*Print Name of Group Member*Date* Date Format: MM slash DD slash YYYY ConneXions Coaching Teleconferencing Software Informed ConsentHaving been fully informed of the risks listed below, I name** hereby give my informed consent to use Skype and/or other teleconferencing software to facilitate coaching sessions with Jodi Hildebrandt and/or any other agent of ConneXions Classroom. Having been informed of the risks of using such software, I, in my sole discretion, request that my ConneXions Coach utilize such software to facilitate my coaching sessions. Risks include but are not limited to: With the use of any teleconferencing software, there is inherent risk of eavesdropping and/or accidental information disclosure. Although ConneXions Coaches do all within our power to ensure the privacy and confidentiality of our clients, nobody can eliminate all risks of electronic information disclosure through the use of teleconferencing software. The use of teleconferencing software requires trust and good faith in the professionalism, trustworthiness, and cybersecurity expertise of multiple outside parties, including, but not limited to, the manufacturers of all utilized computer hardware, operating systems and software (including the teleconferencing software). All of these parties are outside the control of ConneXions Classroom. The use of teleconferencing software necessitates the use of your (the client's) computer hardware and software. Such hardware and software are your responsibility to maintain and are entirely out of the control of ConneXions Classroom. In no case will ConneXions Classroom or any ConneXions Coach be held liable for information disclosure or breaches of confidentiality arising from cybersecurity breaches of your computer equipment, or from negligence, misuse or misconduct involving you or your computer hardware or software, whether caused by you or by others. All Internet-connected technologies present the risks inherent in connecting to the global, publicly-accessible Internet. Software systems of all varieties have been compromised by hackers and other unauthorized agents. Even systems owned by highly-responsible parties such as banks, governments, and militaries—and operated following the most rigorous and complete security practices—have been compromised by bad actors, causing unauthorized access and/or information disclosure. The use of any Internet-connected technology presents such risks. Privacy, confidentiality and cybersecurity are shared responsibilities. Security breaches (such as password leaks) in other websites or Internet services may impact the security and privacy of your teleconferencing experience. Unauthorized access to your computer may likewise impact the privacy, confidentiality and security of other clients of ConneXions Classroom, who also request to use teleconferencing software. Due to the nature of cybersecurity, your confidentiality can be breached if other users of the teleconferencing system experience a cybersecurity breach or through negligence allow unauthorized access to their teleconferencing software. ConneXions Classroom and your ConneXions Coach will in no case be held liable for the actions of you or other clients, and if you request to utilize teleconferencing software, you do so having been fully informed of such risks. ConneXions Coaches expect and encourage all people to be responsible for the risks they choose to take. I understand that my relationship with ConneXions Classroom and any of its agents DOES NOT CONSTITUTE A THERAPEUTIC RELATIONSHIP. I have chosen to participate in coaching with ConneXions Classroom. I understand that the coaching relationship is different from a psychotherapeutic or counseling relationship. The psychotherapeutic relationship places the professional in a position of legal authority and power over the patient. On the other hand, the coaching relationship seeks to eliminate this power differential, and places total power and responsibility for decisions and outcomes in the hands of the client. Responsibilities (such as confidentiality) that would rest solely on the therapist in a psychotherapeutic relationship are instead shared responsibilities in a coaching relationship. As a coaching client, therefore, I understand and agree to take on an added level of trust to maintain the confidentiality of myself and any other clients who may be involved in any teleconferences in which I participate. I understand that my actions do and will affect others, and it is my responsibility to educate myself on responsible use of teleconferencing software and Internet-connected technologies generally, in order to protect myself and others during and after this Internet-mediated coaching experience. I agree to indemnify and hold harmless ConneXions Classroom and all of its agents in the event of any information disclosure or breach of confidentiality arising from the use of teleconferencing software, including but not limited to cybersecurity breaches, hacking attacks, and other types of unwarranted information access. I agree to be responsible for my choice to conduct meetings with ConneXions Coaches via teleconferencing software, and I accept all risks associated therewith, whether known or unknown at the time of signing this document. I accept that there are no guarantees in life, and I agree to use prudence, awareness and good sense and conduct myself wisely and responsibly in my use of teleconferencing software, in order to protect my confidentiality and the confidentiality of any and all others who may also choose to teleconference with ConneXions Classroom. Signature*Date* Date Format: MM slash DD slash YYYY Connexions CoachingAUTHORIZATION OF RELEASE OF INFORMATIONI,Name** whose birthdate isDate* Date Format: MM slash DD slash YYYY *hereby authorize my Connexions Coach and/or Connexions Coaching staff to: Release Information To:*Mailing Address:* Street Address City State / Province / Region ZIP / Postal Code Phone*Alternate Phone:*Relationship to Client:*It is requested that the following specific information be provided: YOU MUST INITIAL THE LINES BELOW.All Session Related Information and Scheduling*Any & All Financial Information Released to Third Party*My Goals and Results*Other (Specify)*Coordination With Other Service Providers*In consideration of this consent, I hereby release Jodi Hildebrandt, Connexions Coaching and Connexions Classroom Inc.and it’s staff from any and all liability arising therefrom.Client or Guardian Signature:*Date* Date Format: MM slash DD slash YYYY
