(Forms can take up to 7 business days to process. You may only select one date and one group for attendance)

Please read this form carefully, then initial on all blanks and sign below.

I understand that:

I will attend and share as a group participant. This means that I live with symptoms of depression or bipolar disorder, or I will attend as a family member/caregiver/supporter of people who live with these disorders (e.g. counselors/nurses will be caregivers for clients/patients in the future).

I will NOT introduce myself as an “observer” or state that I am attending for class credit. I will come to group fully prepared to participate, including sharing about myself and how I am feeling.

I will NOT take any notes during group time or ask facilitator to sign any school documents.

I will maintain confidentiality of all participants/group discussion at all times. This includes any class assignments or discussion. I may not speak/write about any people or content presented in group. I may only talk about my own experience.

I will complete a New Participant Form and Sign the Sign-In Sheet, including phone number.

I will attend the support group by myself. I will not attend with friends or classmates.

I will be respectful to re:MIND facilitator and participants at all times and follow group guidelines.

I understand that re:MIND’s mission is to help individuals with Depression and Bipolar Disorder and I will not hinder this group process in any way.

I have read and fully understand the Student Authorization Form. I understand that, at re:MIND’s discretion, any violation of these policies will result in disciplinary action. This may include contacting my institution and professor or removal from group. I also understand that this signed document will become a part of re:MIND records, and will be stored in accordance with re:MIND record retention procedures.

By typing your name above, you are signing this authorization form electronically.