Holiday Blues Group Quality of Service Survey
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Informed Consent and Participation Agreement

I acknowledge by participating in the free group session sponsored by the Boris L. Henson Foundation, I authorize sharing my registration and its contents (referral) with my chosen provider and/or company. Questions regarding your HIPAA patient rights, responsibilities, and/or release of information must be sent to your treating provider if desired. I acknowledge and give permission for any and all information associated with my registration to be used by the Boris L. Henson Foundation strictly for billing, statistics, and quality assurance. I acknowledge that service fees for special exceptions, insurance copay's, no-shows, and referrals to alternate providers agreed upon between me and my provider are NOT covered by the campaign. I will ensure the mandated Quality of Service Survey is submitted online after EVERY session. I acknowledge that a lack of completion may delay provider reimbursement, scheduling, and lead to removal from the campaign. Break the silence, Break the cycle! BLHF Senior Initiatives Team
Month and Year (XX/XXXX)
Male, Female, Non-Binary
Group Session Date / Time