General Information
The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. This consent will provide a clear framework for your time spent with your assigned wellness coach. Feel free to discuss any of this with me.
The Therapeutic Process
You have taken a very positive step by deciding to seek therapy through the Warrior Golf program. The outcome of your experience depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. I cannot promise that your behavior or circumstance will change. I can promise your wellness coach will do their very best to understand you, as well as to help you clarify what it is that you want for yourself through this 12-week therapeutic relationship. All wellness coaches at Warrior Golf are licensed mental health professionals who are in good standing with their supervisory boards. You will see other names for wellness coach including counselor and psychotherapist below. All these names refer to your wellness coach who will only offer therapy modalities that you are comfortable with. Brief notes are kept in a secure system in order to help track your progress with wellness coaching and refer back to if your coach needs a refresher before your next session. As mental health professionals, our goal is to do no harm to you. This especially applies to taking notes and ensuring there is no incriminating or overly-specific information in our notes that could harm you later on.
Confidentiality
The session content and all relevant materials to the client’s treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such client held privilege of confidentiality exist and are itemized below:
1.If a client threatens or attempts to commit suicide or otherwise conducts themselves in a manner in which there is a substantial risk of incurring serious bodily harm.
2. If a client threatens grave bodily harm or death to another person.
3.If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18years.
4.Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.
5.Suspected neglect of the parties named in items #3 and # 4.
6.
If a court of law issues a legitimate subpoena for information stated on the subpoena.
7.If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney.
8.If you choose to have our sessions in public, on Folly Beach for example. While we will do everything within my power to keep our session content confidential, some confidentiality is lost when meeting in public where other people can see us.
Occasionally we may need to consult with the other professionals within the Warrior Connection to provide the best experience for you. Information about you may be shared in this context without using your name.
If we see each other accidentally outside of the Warrior Golf program, we will not acknowledge you first.Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me first, we will be more than happy to speak with you.
BY SIGNING BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.
Privacy Practices
Warrior Connection Privacy Practices & HIPAA EFFECTIVE DATE OF THIS NOTICE This notice went into effect on April 17, 2023 NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOWYOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I. MY PLEDGE REGARDING HEALTH INFORMATION:
I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me. I need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this mental health care practice. This notice will tell you about the ways in which I may use and disclose health information about you. I also describe your rights to the health information I keep about you, and describe certain obligations I have regarding the use and disclosure of your health information. I am required by law to:
Make sure that protected health information (“PHI”) that identifies you is kept private. Give you this notice of my legal duties and privacy practices with respect to health information. Follow the terms of the notice that is currently in effect.
II. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:
The following categories describe different ways that I use and disclose health information. For each category of uses or disclosures I will explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed.
However, all of the ways I am permitted to use and disclose information will fall within one of the categories.
For Treatment Payment, or Health Care Operations: Federal privacy rules (regulations) allow health care providers who have direct treatment relationship with the patient/client to use or disclose the patient/client’s personal health information without the patient’s written authorization, to carry out the health care provider’s own treatment, payment or health care operations. I may also disclose your protected health information for the treatment activities of any health care provider. This too can be done without your written authorization. For example, if a clinician were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your personal health information, which is otherwise confidential, in order to assist the clinician in diagnosis and treatment of your mental health condition.
Disclosures for treatment purposes are not limited to the minimum necessary standard. Because therapists and other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between healthcare providers and referrals of a patient for health care from one health care provider to another. Lawsuits and Disputes: If you are involved in a lawsuit, I may disclose health information in response to a court or administrative order. I may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:
1.Psychotherapy Notes. I do keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is:
a. For my use in treating you. b. For my use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy. c. For my use in defending myself in legal proceedings instituted by you. d. For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA. e. Required by law and the use or disclosure is limited to the requirements of such law. f. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes. g. Required by a coroner who is performing duties authorized by law. Required to help avert a serious threat to the health and safety of others.
2.Marketing Purposes. As a psychotherapist, I will not use or disclose your PHI for marketing purposes.
3.Sale of PHI.
As a psychotherapist, I will not sell your PHI.
IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION.
Subject to certain limitations in the law, I can use and disclose your PHI without your Authorization fort he following reasons:
1.When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.
2.For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.
3.For health oversight activities, including audits and investigations.
4.For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an Authorization from you before doing so.
5.For law enforcement purposes, including reporting crimes occurring on my premises.
6.To coroners or medical examiners, when such individuals are performing duties authorized by law.
7.For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition.
8.Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.
9.For workers’ compensation purposes. Although my preference is to obtain an Authorization from you, I may provide your PHI in order to comply with workers’ compensation laws.
10. Appointment reminders and health related benefits or services. I may use and disclose your PHI to contact you to remind you that you have an appointment with me. I may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that I offer.
V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.
1. Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.
VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:
1.The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request, and I may say “no” if I believe it would affect your health care.
2.The Right to Choose How I Send PHI to You. You have the right to ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and I will agree to all reasonable requests.
3.The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information that I have about you. I will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and I may charge a reasonable, cost based fee for doing so.
4.The Right to Get a List of the Disclosures I Have Made. You have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, or healthcare operations, or for which you provided me with an Authorization. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures made in the last six years unless you request a shorter time. I will provide the list to you at no charge, but if you make more than one request in the same year, I will charge you a reasonable cost based fee for each additional request.
5.The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that apiece of important information is missing from your PHI, you have the right to request that I correct the existing information or add the missing information. I may say “no” to your request, but I will tell you why in writing within 60 days of receiving your request.
6.The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.
Acknowledgement of Receipt of Privacy Notice
Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By checking the box below, you are acknowledging that you have received a copy of HIPAA Notice of Privacy Practices.
Liability Waiver
The following waiver is required for anyone participating with the Warrior Connection, and states that participants are responsible for themselves before, during, and after participation. By signing this Waiver, you are releasing Warrior Connection from liability for any physical injury or damages to personal property that may occur. Please read this Waiver carefully and completely.
Assumption of Risk I, the undersigned, hereby acknowledge that I (or the minor on whose behalf I am signing) have voluntarily chosen to take part in the Warrior Connection. I hereby further expressly and unequivocally acknowledge my actual and absolute understanding that certain risks are inherent in taking golfing lessons and golfing, and other ocean and beach related activities, and that these risks cannot be eliminated, altered, or controlled; and these; risks can be the cause of injury, illness, death, or other damages. I know and fully understand that golfing is an outdoor activity in an uncontrolled natural environment with inherent risks and hazards where serious accidents and property damage can and do occur, and participants can and do die or sustain injuries.
I do hereby further expressly and unequivocally acknowledge – on behalf of myself or on behalf of the minor for whom I am signing – my full knowledge and understanding that golfing and taking golfing lessons necessarily entail participant exposure to numerous inherent and other known and unknown and unknowable risks, including, but not limited to: (1) loss of control of participant’s golf club or the golf club of another; (2) falls from the golf club; (3) collision with other participants, equipment other golfers or golf clubs, rocks, and/or other man-made or natural obstacles, whether obvious or concealed; (4) the split-second judgment, decision-making and conduct of the instructors (except for acts of wanton or gross negligence); (5) submersion in water and/or drowning; (6) encounters with animals, marine life and insects; (7) exposure to the outdoor ocean environment, extreme temperatures, sun, and inclement weather, including travel by foot or vehicle in any way related to this activity; (8) assistance in lifting and/or carrying golfing equipment; (9) rescue-related injuries; and (10) unavailability of immediate and appropriate medical attention in case of injury. I understand and acknowledge that the above list is not complete or exhaustive, and that other risks, known or unknown, anticipated or unanticipated, may also exist and result in injury, illness, disease, death or damage. My participation (or that of the minor on whose behalf I am signing) in these activities is purely voluntary and I elect to do so (or consent to have the minor on whose behalf I am signing do so) at my/our own risk. By signing this RELEASE, WITH ACKNOWLEDGEMENT AND ASSUMPTION OF RISKS, I do hereby knowingly and lawfully assume all such risk and full responsibility for any consequences of such risk.
Release of Liability For, and in consideration of, the utility, privilege and enjoyment of golfing with the Warrior Connection, I, the undersigned (herein, sometimes referred to as “Releasing Party”), do hereby – on behalf of myself or on behalf of the minor (and also on behalf of all of my or said minor’s heirs, executors, administrators and assigns) – release, acquit and otherwise forever discharge the Warrior Connection and any and all Warrior Connection volunteers, employees, directors, and instructors, and all of their respective owners, officers, agents, employees, members, or assigns (herein, sometimes referred to collectively as “Released Parties’) of and from any and all past, present or future causes of action, claims, demands, damages, costs, loss of services, expenses, compensations, third-party actions, suits at law or in equity, including claims or suits for contribution or indemnity, of whatever nature, and of and from any and all incidental or consequential damages in any way growing out of any personal injury or death or property damage resulting from my participation in any Warrior Connection golfing or other related activity. I understand that I will be participating in activities that include golfing, swimming, holding breath, treading water, significant cardiovascular endurance, physical exercise, and that I am fit to perform those acts. I further contend that I understand that any injuries that may occur, and I release the Warrior Connection from any injuries that may occur during the participation of those previously mentioned activities, and other related activities not mentioned.
Furthermore, to the extent Released Parties ever provide transportation to the beach, I hereby acknowledge and willingly assume, on my own behalf (or on behalf of the minor for whom I am signing) all risks and hazards involved in the activity of riding in a motor vehicle; and I also expressly agree to release and otherwise discharge Released Parties from any act or omission, excluding acts of wanton or gross negligence, in rendering or failing to render any type of rescue, emergency or medical services. In signing this document, I fully recognize and understand that if I (or any minor on whose behalf I am signing) am hurt, die, or my property is damaged, I am giving up my right to make a claim or file a lawsuit against the Released Parties, even if it negligently (or by some other act or omission, excluding acts of wanton or gross negligence) causes the injury or damage.
Indemnify and Hold Harmless I hereby further agree that I (or the minor on whose behalf I am signing) will indemnify and otherwise save and hold Released Parties harmless from and against any and all claims or costs, including attorneys’ fees, of third-parties in any way arising from personal injury, death or property damage to any other participant, spectator or third-party, whether or not resulting from negligence, in the course of my (or the minor’s, on whose behalf I am signing) participation in Warrior Connection activities.
Medical Treatment I consent to medical treatment and medical services that may be required if an injury occurs on-sight. I further acknowledge that in the event medical treatment be required, that my agent or responsible party be required to pay for any medical expenses incurred. Warrior Connection is not responsible for the cost of medical treatment.
Damage to WARRIOR CONNECTION Property I agree to reimburse WARRIOR CONNECTION for any damages to property sustained to WARRIOR CONNECTION golfboards, or other equipment, while under my care.
Successors I understand and agree that this RELEASE, WITH ACKNOWLEDGEMENT AND ASSUMPTION OF RISKS shall be binding upon myself and all of my heirs, assigns and next of kin (or those of the minor on whose behalf I sign), and shall extend to the benefit of Released Parties and their successors and assigns.
Personal Responsibility I, (or the minor on whose behalf I am signing) do not, to the best of my knowledge, have any physical limitation, medical ailment or mental disability that would prevent me (or the minor) from participating in the above mentioned operations and activities. It is my responsibility to disclose any and all impairments that may impact my ability to perform.
Forum Any dispute that may arise out of this agreement is governed by the laws of the State of South Carolina. Any litigation pertaining to this Waiver and Release of Liability Agreement shall be held exclusively in Charleston County, South Carolina, with the prevailing party being entitled to collect reasonable attorney’s fees, costs, and expenses from the non-prevailing party. The undersigned voluntarily submits to the exclusive personal jurisdiction of the state and federal courts in Charleston, South Carolina and waives any and all objections to the jurisdiction or proper forum of such courts.
Severability If any provision of this Waiver and Release of Liability Agreement shall be held unenforceable or void, it shall be severable from the remaining provisions and shall not affect their subsequent enforceability or validity.
Adherence to Policies I hereby agree to abide by all rules, regulations, and instructions of Warrior Connection while participating in all Warrior Connection-related activities. I understand that the Warrior Connection may choose to refuse service to anyone, and if I am in violation of the policies, I may be asked to cease involvement. I understand and agree that Warrior Connection reserves the right to accept or deny service to any person, at any time, and for any reason.
11. Enriching a sense of community within Warrior Connection’s ranks and with the surrounding community is an essential element of our programs. As such, diversity and inclusion is mission-critical. We seek to espouse a collaborative and inclusive culture that connects all stakeholders to the organization, one in which all individuals are able to participate and contribute to their full potential. As a Volunteer with Warrior Connection, you represent our organization. Dialogue and/or behaviors related but not limited to an individual’s origin, language, race, disability, ethnicity, gender, age, religion, sexual orientation, gender identity, socioeconomic status, veteran status, and family structures are prohibited. Warrior Connection reserves the right to discontinue the volunteer relationship in the event a volunteer has failed to comply with this policy.
By signing below, the undersigned (or, if the undersigned is under the legal age of 18, the undersigned’s legal guardian) has read, considered and expressly agreed to all of the terms and conditions of this Waiver and Release of Liability Agreement as of the date written below. This Waiver and Release of Liability Agreement shall be effective and binding upon my heirs, next-of-kin, executors, administrators, assigns and representatives, in the event of my death or incapacity.
Consent for Photography and Videography
By signing this form, I, the undersigned participant (or parent/guardian if the participant is under 18 years old), give my consent to Warrior Connection and its representatives to take photographs and/or video recordings of me during events and activities, including but not limited to golf outings, dinners, support groups, and other Warrior Connection programming.
I understand and agree to the following:
1. Use of Media
I grant permission for my image, voice, and likeness to be used by Warrior Connection for promotional, educational, and marketing purposes. This includes use on websites, social media, newsletters, brochures, presentations, and other outreach or fundraising materials.
2. Ownership
I acknowledge that any photos, videos, or media captured by Warrior Connection or its representatives during my participation become the property of the organization and may be used indefinitely.
3. No Compensation
I understand I will not receive any compensation or royalties related to the use of these images or recordings.
4. Confidentiality
Media will not be taken during private or confidential mental health or chaplain sessions without separate, explicit written permission.
5. Voluntary Consent
My participation is voluntary. I may withdraw my consent at any time by notifying Warrior Connection in writing. Withdrawal will not affect past use of images already published.
6. Liability Waiver
I release Warrior Connection and its representatives from any claims related to the use of my image, likeness, or voice as described above.
Thank you for helping Warrior Connection share its mission and build a community of healing, hope, and connection.
By typing your name below, you agree to the terms above and give your consent:
