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Mobile Sensory Van — Check-In

Log each participant visit to the Mobile Sensory & Recovery Van. Data feeds the reports dashboard for grants.

1 · Consent2 · Visit Details

Privacy & Confidentiality Acknowledgment

Beautiful Wounds Inc. will use reasonable safeguards for information collected during Xavier services. However, privacy is not absolute. Information may be disclosed when authorized by the participant/guardian, when necessary to respond to an imminent safety concern, when required by law or legal process, when mandatory-reporting duties apply, or as permitted/required under an applicable partner agreement.

Only information necessary for the service is collected. Highly sensitive information is not placed on public sign-in sheets.

Adult Participant Informed Consent & Acknowledgment

What Xavier provides

A mobile sensory and recovery environment operated by Beautiful Wounds Inc. Activities may include peer support, psychoeducation, sensory-regulation activities, resiliency education, resource navigation, voluntary screening, and referral to professional/community services.

What Xavier does not replace

Participation is not a substitute for emergency services, medical care, psychiatric care, diagnosis, psychotherapy, or treatment by a licensed clinician. In an emergency or risk of harm, seek immediate emergency assistance.

Voluntary participation and privacy

Participation is voluntary. A participant may decline an activity or ask to leave, subject to site safety rules. Confidentiality may be limited by safety needs, mandatory reporting, legal process, partner-site requirements, or authorization.

Physical/sensory environment

Xavier contains lighting, sound, seating, sensory materials, electronic equipment, and other features. Participants should tell staff if they need an accommodation or if an activity causes discomfort.

Acknowledge all three items and type a signature to continue.