Facilitators will only collect personal information that is needed to help serve you and for statistics. All personal information will be kept in strict confidence.

When a third party needs personal information, a form will be completed with the participant’s knowledge and written consent prior to the exchange of information.

However, a participant’s right to confidentiality is not absolute. It may be superseded when the rights of others are in need of protection and in cases where maintenance of confidentiality may cause serious harm to the participant or to a third party. Release of information to the appropriate authority will only be under the following circumstances:

• A direct threat to harm self
• A direct threat to harm another person
• Child abuse (suspected or based in fact)
• Subpoena

Thank you!

Participant’s Name and Signature		Date
Facilitator’s Name and Signature		Date
Facilitator’s Name and Signature		Date

Adapted from the B.C. Victims of Homicide Resource Guide for Facilitators of Homicide Loss Support Group (March 2014) and Canadian Parents Of Murdered Children’s Rebuilding Shattered Lives pilot project (March – April 2016).