Consent for Data Provided to be Used for Research and Data Collection Purposes


InMindOut Emotional Wellness Center, LLC is continuously searching for the most evidenced-based therapy practices to provide our clients. As such, we are continuing to find ways to improve our knowledge and understanding of therapeutic approaches for our clients. One way to do this is to conduct research on data that the client provides us to ensure best quality of services.

 

  • I consent to have de-identified information that I provided on intake forms, biofeedback/neurofeedback session data, during assessment, and on testing forms used for the purposes of research, supervision, training, and education of clinicians as well as for advertising and marketing purposes.
  • I understand that the information that I provided on intake forms, during assessment, and on testing forms are to be used for research, training, education, advertising and marketing purposes only.
  • I understand that my name, birth date, and any other identifying information will be kept confidential and will not be connected to data used for research or advertising and marketing purposes.
  • I understand that I can terminate this agreement at anytime.

 

If client is a minor, please have the parent or legal guardian sign this form.

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InMindOut Emotional Wellness Center https://inmindout.com
Signature Certificate
Document name: Consent for Data Provided to be Used for Research and Data Collection Purposes
Unique Document ID: 51ab35e82fb64d8f55998be330ed60e99e707b45
Timestamp Audit
October 17, 2017 9:12 am CSTConsent for Data Provided to be Used for Research and Data Collection Purposes Uploaded by imo imo - imo@inmindout.com IP 67.11.9.101
January 15, 2018 11:38 am CST Document owner amanda.bergeron@inmindout.com has handed over this document to imo@inmindout.com 2018-01-15 11:38:42 - 23.122.45.227