In-Person consultations with an AFA Helpline Social Worker

I agree to participate in an in-person dementia care consultation hosted by the Alzheimer’s Foundation of America, Inc. (“Alzheimer’s Foundation of America”) and facilitated by a licensed social worker or Masters level social work student supervised by a licensed social worker employed or engaged by the Alzheimer’s Foundation of America.

I understand, that the Alzheimer’s Foundation of America cannot prevent me or my family from becoming exposed to, contracting, or spreading COVID-19, while participating in therapeutic programs on the Alzheimer’s Foundation of America’s premises. By attending therapeutic programs at the Alzheimer’s Foundation of America, I understand the risk of exposing myself to and/or the increased risk of contracting or spreading COVID-19.

I understand that the Helpline Consultations are confidential, except as mandated by law. In certain situations, Alzheimer’s Foundation of America is required by law to reveal information obtained during a consultation to other persons or agencies without my consent. These situations include, without limitations cases of suspected abuse/neglect of children or the elderly; and cases of potential harm to self or others.

I understand that this group does not take the place of consultation with a physician or other healthcare professional on any issues related to my health and/or formal mental health or substance abuse treatment, and agree to seek assessment and treatment for mental health/substance abuse or other issues by an appropriate clinician should the need arise. Should I have thoughts of harming myself or others, I agree to obtain immediate assistance from a medical professional.

It is the Alzheimer’s Foundation of America’s policy to protect the privacy and confidentiality of individuals. The Alzheimer’s Foundation of America does not share group members’ personal information (i.e., last name, email address, Facebook page, phone number or mailing address), unless required by law as described above.

I hereby forever release, waive and discharge any and all liability, claims and demands of whatever kind or nature against the Alzheimer’s Foundation of America, and its representatives and agents, including without limitations, its owners, officers, directors, managers, trustees, agents, employees, volunteers or other representatives, either in law or in equity to the fullest extent permissible by law, arising from or relating to my participation in a Helpline consultation.

I understand that this agreement means I give up my right to bring any claims including for personal injuries, death, disease, property loss or any other loss, including but not limited to claims of negligence and give up any claim I may have to seek damages, whether known or unknown, foreseen, or unforeseen.