Telehealth Client Consent Form PlacementWorks
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First and Last Name: *
Date of Birth *
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Welcome to Placement Works
Placement Works is offering telehealth counseling and group counseling services, which involves using electronic communications to enable persons at different locations to meet to improve client care. The information may be used for diagnosis, therapy, follow-up, and education, and may include any of the following:

Client health records
Live two-way audio and video
Output data from health devices and sound and video files

At Placement Works, our electronic systems used will incorporate network and software security protocols to protect the confidentiality of client identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

Expected Benefits:

Improved access to care by enabling each client to remain at a remote site or home while the provider offers the counseling service
More efficient client evaluation and management.
Obtaining expertise from a distant specialist.

Possible Risks:

There are potential risks associated with the use of telehealth. These risks include, but may not be limited to:

In sporadic instances, security protocols could fail, causing a breach of privacy of personal health information;

By signing this form, I understand the following:

1. Laws that protect the privacy and the confidentiality of health information also apply to telehealth. No information obtained in telehealth, which identifies me, will be disclosed to researchers or other entities without my consent.
2. I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment.
3. I have the right to inspect all information obtained and recorded in the course of a telehealth interaction and may receive copies of this information for a reasonable fee.
4. A variety of alternative methods of health care may be available to me and that I may choose one or more of these at any time. My provider has explained the alternatives to my satisfaction.
5. Telehealth may involve electronic communication of my personal health information to other practitioners who may be located in other areas, including out of state.
6. I must inform my provider of electronic interactions regarding my care that I may have with other healthcare providers.
7. I may expect the anticipated benefits from the use of telehealth in my care, but that no results can be guaranteed or assured.

Client Consent Form for PlacementWorks
In consideration of my approved attendance at any of the PlacementWorks II Inc. (a 501-c3), Zoom/Video meetings, (the “Event”), I hereby acknowledge and agree:
1. RIGHT TO PHOTOS & VIDEO: I hereby expressly grant to PlacementWorks II Inc. (“GROUP”) and to its officers, employees, agents, and assignees the right to capture, record, and use photographs, video, and/or audio impressions (including live or over the Internet) of me (collectively, “Impressions”) recorded by GROUP at EVENT and to use the photographs and my voice and picture, silhouette, and other reproductions of physical likeness and class-related work (including any still image, videotaped image, captured video-conference image, CD-ROMs, DVDs and/or other analog or digital means, or other media now in existence of hereafter developed), in connection with or as part of any presentation, program, publication, product, transmission, or other professional endeavor in which the same may be used or incorporated, and also in the advertising, and/or publicizing of any such analog or digital works or their content, in perpetuity. I understand these images / sounds may be used for commercial, educational, or informational purposes. I shall not be entitled to any royalties, fees, or other compensation or notice, in connection with any such use. In addition, I waive any claims that any use of my photograph, image, and/or voice as permitted hereunder portrays me in a derogatory manner or false light.
2. OWNERSHIP OF MATERIALS: I agree that GROUP shall exclusively own, jointly and severally, all rights, title, and interest, including copyright in, and to, the complete set of Impressions, with worldwide rights. GROUP shall have the right, for any purpose, to use, adapt, change, delete from or add to such form and content, to combine all or any part of these original recordings with others, and to use, distribute, advertise, market, and otherwise exploit any and all of the foregoing in any manner and in any medium, as GROUP shall determine in its sole discretion. I agree to cooperate with GROUP, at its expense, in all further actions, which GROUP deems necessary or desirable to confirm, register, protect or enforce GROUP's rights in and to such recordings. I waive all rights of copyright or ownership which I might otherwise have in or to any of the products in which my image, likeness, or voice appears, and I agree to assign and do hereby assign, to GROUP any such right, title, and interest in and to any such products. I agree to execute all documents deemed necessary or desirable by GROUP in connection therewith. I waive all rights of copyright or ownership in or to the resulting commercial or educational and informational materials in which I appear, and acknowledge no monetary or other compensation is provided in exchange for waiving this right. I also agree to allow all forms of distribution of any materials that accompany the images or my voice.
3. NO GUARANTEES: The Event will include presentations about income growth opportunities. I understand that there can be no assurance that any prior successes by other individuals, or past results in income earnings, can be used as an indication of my future success or results. I acknowledge monetary and income results are based on many factors. GROUP does not guarantee or imply that I will get rich, that I will do as well, or that I will make any money at all, especially if I do not do the work that’s asked of me or I ignore any other advice presented to me. GROUP’s products may have unknown risks involved and are not suitable for everyone. Making decisions based on any information presented in the GROUP’s products, services, or web site, should be done only with the knowledge that I could make no money at all. All products and services by GROUP are for educational and informational purposes only.
4. DUE DILIGENCE: I agree that I am solely responsible for doing my own due diligence when it comes to making business and financial decisions and all information, products, and services that have been provided by GROUP or at the Event should be independently verified by my own qualified professionals including checking with my accountant, lawyer or professional advisor, before acting on this or any information.
5. RESPONSIBILITY FOR OWN ACTIONS: GROUP’s information, products, and services should be carefully considered and evaluated, before reaching a business decision, on whether to take any action (or refrain from acting). I agree that GROUP is not responsible for the success or failure of my business decisions relating to any information presented at the Event or elsewhere by GROUP or others, or GROUP’s products or services.
6. COPYRIGHT AND CONFIDENTIALITY NOTICE: The materials and resources used in this training are the confidential and exclusive copyrighted and proprietary intellectual property of GROUP. These materials are provided to me by GROUP and solely intended for my personal use as an Event Participant. No part of these documents and/or resources can be stored, reproduced, or transmitted in any form or by any means (electronic, photographic, mechanical, or any other medium), recorded, translated, or used to produce any derivative works without the explicit written permission of GROUP, under the signature. Any violation, or the likelihood of violating, any of my agreements contained in this paragraph, would entitle GROUP to injunctive relief to prohibit any such violations. Should Group commence any legal action in response to my act or omission in violation of this provision, I shall pay all of GROUP’s legal fees and court costs, in addition to all damages requested by GROUP.
7. VIDEOCONFERENCE: I will not display any background image that includes any copyrighted image or logo that I do not own. If I own an image or logo that I display as part of a background, I hereby grant Group a royalty-free and irrevocable license to use said image and/or logo captured as part of the Impressions as otherwise permitted hereunder.
8. LIABILITY WAIVER AND ACKNOWLEDGMENT OF RISK: I understand and agree that in participating in any movement class or workshop that there is a possibility of physical injury. GROUP recommends that I check with my physician before engaging in this class, and I have done so or made a decision that I do not need to do so.
I exempt, release, and indemnify GROUP, its officers, directors, owners, volunteers, assistants, employees, guest artists, faculty members, contractors, and agents, from any and all liability claims, demands, causes of action, damages, injuries, losses, or death, arising in any way (directly or indirectly) in connection with participation in any class or workshop offered by GROUP. I understand that I should be aware of my physical limitations and agree not to exceed them.
I have read and understood the content of this form. I hereby certify that I have read the foregoing and fully understand the meaning and effect thereof, and intending to be legally bound, have signed it on the 'today's date' added below.

I, (First name / Last name) *
I have read and understood the information provided above regarding telehealth, have discussed it with my provider or such assistants as may be designated, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telehealth in my care.
By completing and submitting this form you agree to the terms and conditions. *
Today's Date *
If you are an authorized signer, please describe your relationship with the client, OR write N/A : *
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