I, the above-named participant, agree to participate in session(s) facilitated by Jean E. Tait that will include art therapy. I understand that all artwork and information generated as a product of this event is to be kept confidential and that my identity will be undisclosed. I give permission from the above date forward for my artwork to be shown to professionals for supervision and educational purposes only. I further understand that this type of work can provoke feelings of emotional distress or discomfort.
Additionally, I give permission for photographs to be taken of my artwork for a possible case study, or for presentation and publication for educational purposes, with the understanding that my identity will be disguised to prevent public disclosure.
If you do not want your work to be photographed, check below.
I understand that all information will be kept confidential unless:
- There is a threat of bodily harm to myself (including suicidal thoughts) or others;
- There is an indication of child, elder, or vulnerable person abuse;
- Information is requested by subpoena for court purposes.
By indicating below my acceptance of this agreement, I:
- acknowledge that I have read this Release and Consent Agreement and understand it and I freely elect to participate, and
- take full responsibility for telling Jean E. Tait if I feel at any point disturbed by my participation, and
- release Jean E. Tait from any claims of malpractice, nondisclosure, or lack of informed consent, and
- freely assume responsibility for any and all risks of the work conducted by Jean E. Tait, whether presently contemplated or hereinafter discovered.
I understand that I may withdraw consent at any time by giving verbal or written notice.
