BetterHelp Program Acknowledgement and Waiver Form

Please read the following information and complete the form below if you are interested in receiving information on how to register for services offered through BetterHelp. You will receive an email within 72 hours on how to register with BetterHelp and access the services they offer.

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 BetterHelp to provide me access to BetterHelp’s Provider Network (therapists, counselors, marriage and family therapists, social workers, psychologists, etc.) who will provide their services at no-cost to me.

Everytown cannot and does not provide any warranties or endorsements related to the services provided by any of the mental healthcare providers listed in BetterHelp’s Provider Network, who I understand are not employees or agents of Everytown.

Whether I find BetterHelp 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 BetterHelp 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 counseling or services I receive through the BetterHelp 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 may share my name and contact information with the BetterHelp Program for the purpose of registering me with the service and that any information I provide to BetterHelp will be governed by BetterHelp’s privacy policy (available here).

I understand that my medical and mental health information acquired as a result of engaging in counseling with a BetterHelp provider is protected by HIPAA privacy laws and Everytown will never have access to this information. By completing this form, I am confirming only that I would like to receive information on how to access BetterHelp.

In partnership with Everytown, BetterHelp is providing access to counseling with licensed mental health professionals at no-cost to the individual using the service. Please note that BetterHelp is the largest online therapy platform in the world. Counseling is provided in one of four ways:

-Exchanging messages with your counselor
-Chatting live with your counselor
-Speaking over the phone with your counselor
-Video conferencing with your counselor

I understand that Everytown may contact me in the future to solicit feedback regarding BetterHelp’s services, but that any such contact will be voluntary, anonymous, and general in nature.

Instructions on how to begin will arrive in your inbox shortly. If you do not hear from anyone for any reason within 72 business hours, please reach out to betterhelp@everytown.org. Thank you for your interest!

Question Title

* 1. Please provide us with your contact information

Name

Address and Suite or Apartment Number

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

Question Title

* 2. Are you a member of the Everytown Survivor Network?

Yes

Not Sure

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* 3. How did you hear about the Everytown Survivor Network BetterHelp Program?

Email from Everytown/Moms Demand Action

Social Media Posts from Everytown/Moms Demand Action

Everytown/Moms Volunteer or Staff

Other (please specify)

Question Title

* 4. I would like to receive information about how to access BetterHelp

Yes

Question Title

* 5. Initials to acknowledge and agree to the waiver

PLEASE NOTE: AFTER SUBMITTING THIS FORM, YOU WILL RECEIVE AN EMAIL DIRECTLY FROM BETTERHELP. THE EMAIL ADDRESS IS CONTACT@BETTERHELP.COM. PLEASE CHECK YOUR INBOX, SPAM FOLDER, TRASH FOLDER, AND PROMOTIONS FOLDER. IF YOU HAVE TROUBLE ACCESSING, EMAIL THE EVERYTOWN SURVIVOR NETWORK TEAM AT BETTERHELP@EVERYTOWN. ORG.