Please read the mandatory disclosure statement carefully
Informed Consent & Peer Facilitation Agreement
UNBREAKABLE MEN CO is a Multi-State/International Non-Clinical Peer Support Group
A. NON-CLINICAL SCOPE OF SERVICE & JURISDICTIONAL DISCLOSURE > COLORADO STATUTORY NOTICE & MULTI-STATE JURISDICTIONAL WAIVER: > While the group facilitator, Kevin Taylor, is a Licensed Professional Counselor (LPC) in the State of Colorado, he is not acting in a clinical capacity, dispensing psychological advice, conducting clinical evaluations, or delivering psychotherapy within this space. This peer support group is explicitly a non-clinical wellness service operating as an exempt service pursuant to Colorado Revised Statutes § 12-245-217(2)(f).
Because this group does not provide psychotherapy or clinical counseling, it is not bound by geographic telehealth restrictions or medical licensing jurisdictions. By participating from any state outside of Colorado or country outside the United States, you explicitly acknowledge that you are joining a Colorado (US) -originated non-clinical peer circle and agree that these services are completely exempt from professional mental health regulatory board oversight in both Colorado (US) and your home state or country. Peer support groups are constructed around mutual aid, shared lived experiences, and collaborative community resilience. This group is designed exclusively for personal enrichment, peer encouragement, and psychoeducation. It does not establish a psychotherapist-client professional relationship.
B. CLEAR BOUNDARIES OF PRACTICE By executing this agreement, you acknowledge and accept the following structural constraints:
No Assessment or Diagnosis: No diagnostic mental health impressions (DSM-5 / ICD-10) will be formulated, tracked, or assigned.
No Treatment Plans: There are no clinical objectives, therapeutic modalities, or medical treatment strategies applied.
Participant Accountability: If you are presently experiencing acute psychiatric distress, severe trauma flashbacks, active substance withdrawal, or a major mental health crisis, you recognize that this environment is structurally ill-equipped to treat these conditions. You agree to seek dedicated clinical care from an independent licensed medical or mental health specialist in your home state.
C. FINANCIAL TERMS & STRICT INSURANCE EXCLUSION Participation in this peer support group requires a structured fee of $30 per session or agreed/waived amount. Because this service is strictly non-clinical:
1. Refund Policy
Services Rendered: All fees paid for attended support groups are final and non-refundable.
Provider Cancellation: In the rare event that Kevin Taylor MA LPC NCC must cancel a session, group meeting, or training event due to unforeseen circumstances, a full refund or an immediate opportunity to reschedule will be issued to the client.
2. Payment Terms: Payments must be rendered via secure third-party payment gateway prior to support group meeting and agree to maintain valid payment (credit card or ACH details) .
3. Dispute Resolution: Any legal disputes shall be governed by the laws of the State of Colorado, with venue residing in El Paso County
No Insurance Reimbursement: Under no circumstances will standard medical insurance codes, CPT codes, or clinical superbills be generated.
Submission Prohibited: You expressly agree that you will not submit receipts or invoices from Unbreakable Men CO to Health First Colorado (Colorado Medicaid), Medicare, or any private, public, commercial, or out-of-state health insurance company for reimbursement. Doing so could constitute a misrepresentation of non-medical services.
By submitting your name you agree to abide by and accept these policies in terms of group rules, payment, and privacy, I have read all the information herein. I understand the disclosures that have been made to me. I also acknowledge that I have been offered and may receive a copy of this Disclosure Statement if requested. I enter this agreement.
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1. I understand the group is for non-offending survivors, and I will be dismissed from the
group to maintain the safety and comfort of group members if it is discovered that I have
committed a sexual offense.
2. For meetings on Zoom I understand that my video must be viewable. It is not fair to the
group to remain anonymous while other group members show themselves. Part of the
purpose of the group is to confront secrecy, be authentic and vulnerable.
3. I will not be under the influence of alcohol or drugs while in group and understand if I
fail to follow this rule, I will be asked to leave the meeting.
4. I promise to uphold confidentiality. No audio or video recording of any meetings is allowed. Whatever is shared here, stays here, including refraining from talk about others when they are not present.
5. I will share my feelings and experiences without giving unsolicited advice, and I will
make an effort not speak out of turn and to use “I” statements instead of “you”
statements.
6. I understand participation will allow me to get more out of the group while maintaining
the right to pass and not speak. Sharing your story is optional but always welcome when
you are ready.
7. I will not discriminate on the basis of race, ethnicity, sexual orientation, or religion,
understanding faith/religion is a personal experience to be expressed but not to be
imposed upon others and that politics is not an appropriate subject to be discussed.
8. I understand I am responsible for myself and will take care of myself if I am triggered or
upset by others’ sharing.
9. I will not disclose the identities, names, professions, or personal details of any other group participant outside of this space.
10. I will not share personal narratives or experiences heard in the group with family, friends, or on social media, even if anonymized.
[LIMITATION OF PRIVACY LIABILITY: While the facilitator will strictly safeguard group information, you acknowledge that the facilitator cannot legally control or guarantee the perfect compliance of peer participants. By submitting you name below, you agree to release the facilitator from any liability should a peer member breach this trust.]
D. MANDATORY REPORTING AND MULTI-STATE LEGAL LIMITS OF CONFIDENTIALITY Although this is a peer support environment rather than a counseling clinic, the facilitator is a mandated reporter under Colorado law due to his professional credentials. The facilitator must breach confidentiality and report information to appropriate protective or emergency services in the following specific circumstances, regardless of your geographic location:
Abuse or Neglect: If there is any reasonable suspicion or explicit report of ongoing child abuse, child neglect, or the abuse, neglect, or financial exploitation of an at-risk elder or vulnerable adult (pursuant to Colorado Revised Statutes and corresponding mandatory reporting statutes in the participant's resident state).
Imminent Threat to Others (Duty to Protect / Tarasoff Mandate): Pursuant to C.R.S. § 13-21-117 and equivalent safety doctrines nationwide, if a participant communicates an explicit and imminent threat of serious physical violence against a clearly identifiable third party, the facilitator is legally required to notify law enforcement in the participant's local jurisdiction and take reasonable steps to warn the intended victim.
Imminent Threat to Self: If a participant demonstrates an imminent, active intent to end their own life, the facilitator will step in to ensure their safety by contacting emergency dispatch or mobile crisis clinicians in the participant's specific local municipality.
E. OPERATIONAL CRISIS AND SAFETY PROTOCOL > EMERGENCY NOTICE & GEOGRAPHIC RESPONSIBILITY: Unbreakable Men CO does not maintain an active medical on-call answering service, 24/7 crisis lines, or any other clinical psychiatric service. Because this group accommodates out-of-state/country participants, the facilitator cannot directly dispatch local Colorado emergency teams to your location. You are responsible for knowing your immediate local emergency contacts.
By signing below, you agree that you are aware of and will utilize the following emergency crisis resources if an immediate risk of harm arises:
National Suicide & Crisis Lifeline: Dial or text 988 (Available nationwide, connects to your local regional crisis center).
The Crisis Text Line: Text HOME to 741741.
Colorado Crisis Services (For CO Residents Only): Call 1-844-493-8255.
Local Emergency Response: Dial 911 or report directly to the nearest hospital emergency department in your local city and state.
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