Together We Heal — Informed Consent & Liability Waiver

Part One — Informed Consent

Overview

Together We Heal is a biweekly virtual support group organized and hosted by United by Culture Media ("UBCM"), a nonprofit organization located at 14301 FNB Parkway, Ste. 100, Omaha, NE 68154. Sessions are co-facilitated by Miguel Estevez Jr., LIMHP, LPC, NCC, and Gladys Godinez.

Participants must be adults (18 years of age or older).

Consent to Participate

I voluntarily choose to participate in Together We Heal group sessions hosted by UBCM. I understand that session format, schedule, and facilitators may change at UBCM's discretion based on participant needs or other circumstances.

I understand that Together We Heal is a peer support and psychoeducational space, and is not a substitute for individual therapy, medical treatment, or crisis intervention. I understand that my participation in this group does not establish an individual therapist-client relationship with Miguel Estevez Jr. or any facilitator.

I understand that my participation is entirely voluntary. I may choose to stop attending or withdraw from the group at any time, for any reason, without penalty or obligation to explain my decision.

Facilitator Disclosure

Miguel Estevez Jr. is a Licensed Independent Mental Health Practitioner (LIMHP) in Nebraska, a Licensed Professional Counselor (LPC) in Colorado, and a National Certified Counselor (NCC). He facilitates Together We Heal in a group support and psychoeducational capacity, not as a treating clinician. Questions or concerns about Miguel's clinical licensure may be directed to the Nebraska DHHS Division of Public Health, Licensure Unit, at (402) 471-4905, or dhhs.ne.gov/licensure.

Participant Expectations & Code of Conduct

All participants agree to:

  • Treat others with respect and contribute to a safe, inclusive environment.

  • Maintain the confidentiality of anything shared by other participants in the group.

  • Refrain from recording, screenshotting, or otherwise capturing sessions without the explicit consent of the group.

  • Follow instructions provided by UBCM facilitators.

  • Refrain from disruptive or inappropriate behavior.

UBCM reserves the right to remove any participant from the group for behavior that violates these expectations or poses a risk to others.


Technology & Privacy Acknowledgment

I understand that virtual meeting platforms carry inherent risks, including technical failure, interrupted connectivity, or unauthorized access, despite UBCM's reasonable efforts to limit session access to approved, registered participants.

I am responsible for joining sessions from a private space where my participation and what I share cannot be overheard by others, in order to protect my own confidentiality and that of other participants.


Mental Health Authorization

I authorize UBCM to contact my designated emergency contact if a facilitator has a good-faith concern for my immediate safety or well-being during or following a session.

I understand that UBCM and its facilitators are not a substitute for emergency services. In a life-threatening emergency, I will contact 911 or my local emergency line directly. If I am experiencing a mental health crisis, I understand facilitators may share crisis resources with me and, if appropriate, contact my emergency contact.

Confidentiality

UBCM and facilitators agree to keep group session content confidential, except where disclosure is required by law. This includes mandatory reporting obligations for suspected abuse or neglect of a child or vulnerable adult, and situations involving imminent risk of harm to self or others.


I agree to keep confidential anything shared by other participants in the group, and not to disclose other participants' identities, stories, or shared information outside the group without their explicit consent.


I understand that while all participants agree to this confidentiality expectation, UBCM cannot guarantee that other participants will maintain it outside the group. Complete confidentiality cannot be guaranteed with absolute certainty in any group setting, and I agree to do my part to protect it.

Part Two — Waiver & Release of Liability

Acknowledgment of Risk & Waiver of Liability

I understand that participation in Together We Heal may involve inherent risks, including but not limited to: emotional or psychological discomfort arising from discussion of sensitive topics related to advocacy work, burnout, and secondary trauma; technology-related risks; and risks related to interactions with other participants.

I voluntarily assume all risks associated with participation.

To the fullest extent permitted by law, I agree to release, waive, and hold harmless UBCM, its directors, officers, employees, volunteers, contractors, agents, and representatives (including facilitators) from any and all claims, liabilities, damages, or causes of action arising out of or related to my participation in Together We Heal, except to the extent caused by gross negligence or willful misconduct.

I understand this waiver is intended to be as broad as permitted by applicable law and does not waive rights that cannot legally be waived.

Governing Law & Severability

This agreement is governed by the laws of the State of Nebraska.

If any provision of this waiver is found to be unenforceable or invalid, that provision will be limited or removed to the minimum extent necessary, and the remaining provisions will remain in full force and effect.

Electronic Signature

By checking the acknowledgment box and typing your name in the registration form, you are providing your electronic signature. This electronic signature carries the same legal effect as a handwritten signature.