CONSENT FOR SERVICES: I hereby voluntarily consent to Trustbridge Bereavement Center to provide bereavement grief support services, including (but are not necessarily limited to) individual support, group support, virtual sessions, or education by employees or authorized agents of Trustbridge, Inc.

CONFIDENTIALITY/PATIENT RIGHTS: I understand that Trustbridge Bereavement Center clinicians maintain confidentiality of client information in accordance with the Health Insurance Portability and Accountability Act (“HIPAA”) and other applicable, Federal, State and other regulations. I understand that if I choose to participate in a virtual session, it is my responsibility to be in a private room or space and if not, my conversations may be overheard by others. I have been informed of my rights and have received a copy of Trustbridge’s Notice of Privacy Practices and Patient Rights & Responsibilities.