Virtual Support Request Form

DISCLAIMER AND CONFIDENTIALITY POLICY PLEASE READ. Care Net Pregnancy Center of Southern Maryland (Care Net SoMD) is a non-profit organization. The staff and/or volunteers who will be meeting with you via video conferencing have received training in crisis counseling; but they do not have degrees in counseling nor are they licensed by the state. The counseling provided is not intended as a substitute for professional counseling. We offer information and practical help. Care Net SoMD does not provide or refer for abortions. All information is kept confidential. Occasionally, in order to offer you the best possible alternatives, your client advocate may seek the advice or assistance of the Director or the Nurse manager. Any subsequent discussion of your circumstances with Care Net SoMD staff would occur with your well-being in mind. All information which is shared is kept confidential within the Care Net SoMD ministry and will not be discussed or released outside the center without your express consent. As mandated reporters, we are required to report knowledge of a client who is suicidal, homicidal, abusing a minor, a minor being abused, or a victim of statutory rape. By signing below I acknowledge the above information and that the client advocate has my permission to inform me about my options. I will not record any part of this or future visits to the center.By typing your name in the box above, you acknowledge that you have read and agree to the disclaimer at the top of this form.