CONFIDENTIAL CONSENT FORM

 EMPLOYEE MENTAL WELLBEING PROGRAM

Consent Agreement:
I, the undersigned, understand that my participation in the Employee Wellbeing Support program is voluntary and intended to provide confidential support for personal or work-related concerns.

I acknowledge and agree to the following:

  1. Confidentiality
    All information shared during will remain strictly confidential. No details about my participation, session content, or personal information will be shared with my employer under any circumstances, except as required by law. Exceptions include cases involving:

    • Threats of harm to self or others.

    • Suspected abuse or neglect of a minor, elder, or dependent adult.

    • Compliance with a legal court order.

  2. Voluntary Participation
    My participation in the wellbeing support program is entirely voluntary, and I may choose to discontinue services at any time.

  3. Release of Information
    I consent to the release of information to authorized Pacific Mindful Wellbeing @ Work personnel solely for the purpose of coordinating and managing services. This release does not include the employer or its representatives. No information will be disclosed to my employer without my explicit written consent.

  4. Service Limitations
    The Wellbeing Support program is a short-term support service and does not replace long-term counseling or medical care. It is not a crisis service. Referrals to external resources may be provided if additional support is needed.

  5. Acknowledgment of Terms
    By signing below, I confirm that I have read, understood, and agree to the terms outlined above.

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