ACT Support Group Registration

AWAA
6723 Whittier Ave, #202
McLean, VA 22101
http://www.awaa/act.org

Participant & Support Group Information

Have you used AWAA for either placement or social services? *

Household / Adult Primary Contact

Relationship to Participant: *
 

Payment

To pay online please go to AWAA's Payment Webpage and choose "Adoption Education Webinar" as the payment option. A small convenience fee will apply. You will receive an immediate email confirmation of your payment. Please forward this receipt to act@awaa.org.

Vital information about Group Participation

 

How do I participate in a session?

            We have arranged an account with “GoToMeeting,” a HIPPA-compliant, video-conference platform, to serve as the communication provider for ACT. Once you have registered for the group (by returning this form and sending in payment), you will be sent information by email about how to log into the session. You can participate through your computer, tablet, or most smart-phones. If you have a webcam or camera on your device, you will likely be able to make yourself visible on the screen, and your coach and other group members will do the same. Up to 6 people can be seen on 1 screen, “Brady Bunch” style. Or, you can choose to not show yourself, though we highly encourage all group members to use their camera if possible to increase communication through facial expressions and body language. You will be able to use the audio functions through your electronic device to talk and hear, or alternatively, a phone number will be provided for you to call into the session if that works better for you.

 

What are the qualifications of the person I will be working with?

            ACT coaches are AWAA staff members with training in adoption issues. All have Master’s degrees and experience in counseling or coaching, and training in Trust Based Relational Intervention© or other adoption-specific concepts and methods.

 

How do I pay?

Online payment of fees is preferred in order to have quick confirmation of payment, and you can make a payment at https://portal.awaa.org/forms/payment.aspx and choose “Adoption Education Webinar” as your type of fee, and put your group name in the notes. A small convenience fee for online payments will apply.

There are no refunds for group session payments.

 

What if I need to cancel or reschedule, or am running late?

Please give as much notice as possible if you cannot attend an appointment.

For ongoing weekly groups, if you cancel an appointment with at least 24 hours notice, the prepaid fee may be applied to the next session. Fees for appointments that are cancelled with less than 24 hours notice, or not attended at all (“no-show”) will be forfeited.

For “limited number of session” groups or webinars, there are no “make-up” sessions or refunds for missed groups

If a client arrives late for an appointment, no refund is given for time not spent in session, nor is the coach obligated to continue the session past the normally scheduled end-time.

 

How do I contact my Coach?

                        Email is the best way to reach your coach, and he or she will provide you with an email address once you have registered. You may also call the main AWAA office at 800-466-8922 during normal business hours to have a phone message relayed to your coach. Coaches are instructed to return all calls and emails within two business days unless notification is given that they are unavailable for a certain amount of time. If necessary, you may reach out to an AWAA Clinical Supervisor, the ACT Coordinator, or Director of Affiliate Offices at the above phone number for any urgent needs during normal business hours.

 

What if our family has a crisis or emergency?

If you have an emergency, please call 911 or report to a hospital emergency room. Our staff is not available on a 24-hour basis, nor are we able to respond immediately to a crisis.

 

How do I file a complaint if I am not satisfied?

            If you are dissatisfied with the services you are receiving for any reason, please talk with your coach or another AWAA staff member about your concerns. Additionally, or in place of talking with staff, you may file a grievance. You may ask for a specific form from staff, or send and email to an executive staff member at AWAA. Grievances will be reviewed and addressed by the Performance Quality Improvement team.

 

What about my privacy and confidentiality?

All information you share is confidential except as follows:

  • You consent to the release of information by written statement.
  • There is a court order or law enforcement entity requiring the release of information.
  • Child abuse, neglect, criminal activity, or harmful intention is suspected. If we are concerned about any type of child abuse or neglect, or other imminent harm, we are legally and ethically obligated to report that information to authorities.
  • Charges or a complaint are brought against this coach or agency related to the client.

You have the following rights regarding your records that we keep:

  • You have the right to inspect and be given a copy of records ($.10/copy) (not including progress notes.)
  • You may ask us to amend the information if you feel that information we have about you is incorrect or incomplete.
  • You have the right to request a list of the disclosures we have made of your information.
  • You have the right to withdraw or restrict any release of information you have previously given. However, we must receive your restrictions or withdrawal in writing before we have made such disclosures. Also, if you restrict our right to share your information with other professionals providing care for your family, we reserve the right to immediately withdraw our services.

 

 

Agreement

Except for claims arising from the gross negligence or willful misconduct of AWAA, the family waives, releases and forever discharges any and all rights, claims demands and/or causes of action that the family and any of their minor children may have against America World and/or any of its officers, directors, employees, contractors, volunteers, or other agents, including claims for bodily injury or property damage or any other type of loss arising out or resulting from the adoption process. The family acknowledges that third parties not subject to the direction or control of America World - including, but not limited to the video conference platform provider -- may be involved in the coaching process, and hereby agrees to release and hold AWAA harmless for any acts and/or omissions of any and all third parties.

 

Family further agrees to indemnify, defend and hold harmless AWAA and any of its directors, officers, employees, agents, contractors, volunteers, or other agents from any and all claims, demands, losses, causes of action, damages, lawsuits, judgments, including attorney’s fees and costs, or other liabilities arising now or in the future. This waiver includes any and all claims, demands, causes of action, or other liabilities arising out of the family’s negligent or intentional acts and/or omissions, including any and all intentional or negligent acts and/or omissions resulting in injury to a child.

 

This agreement, in conjunction with adoption process related agreements previously executed with America World, represent the entire agreement between America World and the family, and supersedes any contrary oral or written representations. In the event that any term or condition in this agreement is held to be invalid, illegal or unenforceable for any reason, such invalidity, illegality or unenforceability shall not affect any other term or condition in this agreement or other agreements with America World. In the event of such determination, this agreement shall be interpreted and construed as if such term or condition had never been contained herein, but as closely to the original intent of the parties as possible.

 

The agreement is governed by the laws of the commonwealth of Virginia.

 

The parties recognize that conflicts or disputes may occasionally arise, and shall utilize best efforts to resolve any and all conflicts or disputes in private meetings between the parties or through our formal grievance process. If any dispute cannot be resolved in private meetings or through the grievance process, the parties agree, as an alternative to litigation, to enter mediation and, if mediation is unsuccessful, legally binding arbitration in accordance with the rules of the Christian conciliation institute of peacemakers ministries as set forth at http://www.peacemaker.net. The parties agree that any arbitration award may be entered in any court having jurisdiction over the subject matter or parties. The parties understand that these methods shall be the sole remedy for any controversy or claim arising out of this agreement or the subject matter hereof, and expressly waive their right to file a lawsuit or claim against one another for such disputes, except to enforce an arbitration decision.

 

I/We have read, understood, and agree to all of the above information concerning AWAA’s ACT Groups:

Adoptive Parent Signature (Sign your name using your mouse) *
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