Give an Hour: Acknowledgement and Waiver Form |
I understand that the Everytown Survivor Network (together with Everytown for Gun Safety Support Fund and Everytown for Gun Safety Action Fund, Inc., “Everytown”) has collaborated with Give an Hour to provide me access to Give an Hour’s Provider Network (therapists, counselors, marriage and family therapists, social workers, psychologists, psychiatrists, nurse practitioners, etc.) who provide one hour of counseling services per week free of charge (the “Give an Hour Program”).
Everytown cannot and does not provide any warranties or endorsements related to the services provided by any of the mental healthcare providers listed in the Give an Hour’s Provider Network, who I understand are not employees or agents of Everytown.
Whether I find the Give an Hour Program successful may depend on the healthcare provider(s) with whom I am matched or choose, over which Everytown has no control or responsibility. Everytown does not and cannot guarantee that I will be satisfied with the Give an Hour Program.
I agree that I will not file a lawsuit against Everytown or any of its donors based on claims that arise out of or relate in any way to the counselling or services I receive through the Give an Hour Program.
I understand that in the case of a mental health or medical emergency, it is my responsibility to call 911 for emergency services.
I understand that Everytown and the Give an Hour Program may share my name and contact information with each other to facilitate a referral to a mental healthcare provider as part of the Give an Hour Program.
I understand that my medical and mental health information acquired as a result of engaging in counseling with a Give an Hour Program provider is protected by HIPPA privacy laws and Everytown will never have access to this information.
Everytown cannot and does not provide any warranties or endorsements related to the services provided by any of the mental healthcare providers listed in the Give an Hour’s Provider Network, who I understand are not employees or agents of Everytown.
Whether I find the Give an Hour Program successful may depend on the healthcare provider(s) with whom I am matched or choose, over which Everytown has no control or responsibility. Everytown does not and cannot guarantee that I will be satisfied with the Give an Hour Program.
I agree that I will not file a lawsuit against Everytown or any of its donors based on claims that arise out of or relate in any way to the counselling or services I receive through the Give an Hour Program.
I understand that in the case of a mental health or medical emergency, it is my responsibility to call 911 for emergency services.
I understand that Everytown and the Give an Hour Program may share my name and contact information with each other to facilitate a referral to a mental healthcare provider as part of the Give an Hour Program.
I understand that my medical and mental health information acquired as a result of engaging in counseling with a Give an Hour Program provider is protected by HIPPA privacy laws and Everytown will never have access to this information.