For Individuals: Healing the Wounds Workshop Intake Form
Confidentiality Agreement
As a participant in the Healing the Wounds workshop, you are entitled to confidentiality as outlined by the Alberta College of Social Workers (ACSW) Code of Ethics and International Coaching Federation (ICF). This agreement is designed to protect your privacy and ensure a safe environment for healing and growth.
Confidentiality Statement
All information shared during the workshop, including personal experiences, discussions, and any written materials, will be kept strictly confidential by the facilitator.
The facilitators are bound by professional ethics and legal requirements to maintain confidentiality, except in the following circumstances:
If there is a risk of imminent harm to yourself or others.
If there is suspicion of child abuse or neglect.
If required by a court order or other legal proceedings.
If the workshop is in a group setting, participants are also expected to maintain the confidentiality of others’ shared experiences and information. However, the facilitators cannot guarantee that all participants will adhere to this expectation.
Any written records or notes taken during the workshop will be stored securely and accessed only by authorized personnel.
Anonymized data may be used for research or educational purposes, but no identifying information will be disclosed without your explicit consent.
If you have any concerns about confidentiality, please discuss them with the facilitators.
By participating in the Healing the Wounds workshop, you agree to respect the confidentiality of all participants and adhere to these guidelines.
Insurance Information and Agreement
Please read and acknowledge the following:
The Healing the Wounds workshop, which includes psychoeducation, healing exercises, and coaching, has a fee of $450 per client.
By completing this form, you agree to the workshop fee and understand that payment is required to secure your participation.
Please provide your insurance information below. If you plan to seek reimbursement from your insurance provider, it is your responsibility to confirm coverage for this type of workshop.
By entering my full name in this online form, I hereby acknowledge that I have read, understood, and agree to the terms and conditions regarding confidentiality and privacy as outlined in the Healing the Wounds Workshop Intake Form. This includes the confidentiality agreement and related insurance information. I understand that my participation in the workshop is subject to these terms and that my personal information will be handled in accordance with the stated privacy policies.