REFLEO HEALTH, INC.

PARENTAL CONSENT AND AUTHORIZATION

For a young person who is at least 13 and under 18

Form version 1.0

Please read this before your child begins using Refleo. It is short on purpose. If anything here is unclear, ask your child's clinician before you sign.

Who this form is :

Young person's name: ___________________________________________

Date of birth: ___________________________________________________

Clinician or practice: _____________________________________________

Your name: ____________________________________________________

Your relationship to the young person: _______________________________

1. What Refleo Is

Your child's clinician uses Refleo to stay connected between appointments. Between sessions, your child records short voice or text entries about how they are doing. Refleo organizes those entries, identifies recurring themes, and highlights topics the clinician has chosen to track. Before the next appointment, the clinician reviews a short summary together with the entries themselves.

That is all Refleo does. It is a tool your child's clinician uses. It does not change who provides your child's care.

2. What Refleo Is Not

Please read this section carefully. It is the most important part of this form.

Refleo does not provide counseling, therapy, advice, diagnosis, or treatment. It never responds to your child, never offers guidance, and never tells your child what to do.

REFLEO IS NOT A CRISIS SERVICE AND IS NOT AN EMERGENCY SERVICE. NO ONE AT REFLEO READS OR LISTENS TO ENTRIES AS THEY ARE SUBMITTED. ENTRIES GO TO YOUR CHILD'S CLINICIAN, WHO MAY NOT SEE THEM UNTIL THE NEXT APPOINTMENT OR LATER.

IF YOUR CHILD IS IN DANGER, IS THINKING ABOUT SUICIDE OR SELF HARM, OR NEEDS HELP RIGHT AWAY, CALL OR TEXT 988 (SUICIDE AND CRISIS LIFELINE), CALL 911, OR GO TO THE NEAREST EMERGENCY ROOM. DO NOT USE REFLEO TO ASK FOR URGENT HELP.

Your child's clinician has a separate process for urgent needs between appointments. Please make sure that you and your child know what that process is. Refleo is not part of it.

3. How the Entries Are Handled

Refleo uses automated technology, including artificial intelligence, to turn recordings into text and to summarize them. Automated technology can be incomplete and can be wrong. Your child's clinician reviews the underlying entries and uses their own professional judgment.

Your child's entries become part of the record of care that the clinician keeps. Refleo holds that information on the clinician's behalf under a written agreement required by federal health privacy law.

Refleo does not sell your child's information. Refleo does not use it for advertising. Refleo does not use information that identifies your child to train artificial intelligence models.

4. What You Are Agreeing To

By signing below, you confirm and agree that:

You are the parent or legal guardian of the young person named above and you have the legal authority to make this decision. If custody or decision-making is shared, you confirm that you have the authority to give this consent.
The young person named above is at least 13 years old. Refleo is not available to children under 13.
You consent to the young person using Refleo as part of their care with the clinician named above.
You authorize the clinician named above to disclose to Refleo Health, Inc. the young person's health information created through or needed to operate Refleo, including voice and text entries, transcripts, summaries, and related account information, and you authorize Refleo to receive, hold, and return that information. The purpose is to support the young person's care with that clinician.
This authorization remains in effect until you revoke it, until the young person's care with the clinician ends, or until the young person turns 18, whichever comes first.
You have read Sections 2 and 3 and you understand that Refleo is not counseling and is not a crisis service.
You accept the Refleo Terms of Service and the Refleo Privacy Policy on the young person's behalf. Both are available at https://refleohealth.com/terms and https://refleohealth.com/privacy.
You understand that information disclosed under this authorization may be redisclosed by the person who receives it and may then no longer be protected by federal health privacy law. Refleo remains bound by its written agreement with the clinician and by its Privacy Policy.

5. Privacy, and What You Will and Will Not See

Your child's entries go to the clinician, not to you. What the clinician shares with you is a clinical and legal decision that the clinician makes, guided by state law and by their professional obligations. Refleo does not make that decision and does not release information to anyone except at the clinician's direction.

If you want to see, correct, or obtain a copy of your child's information, ask the clinician. Those requests run through the clinician and not through Refleo. If you send a request to Refleo, Refleo will forward it to the clinician.

6. Reminders and Messages

Refleo may send reminders by email or text message to the address or number you or the clinician provide, so that the young person remembers to record entries. Message and data rates may apply. You can stop text messages at any time by replying STOP, or you can ask the clinician to turn reminders off.

7. This Is Your Choice

You do not have to agree to this. Your child's care does not depend on it, and the clinician will not condition treatment on your signing this form. If you decline, the clinician simply will not use Refleo with your child, and everything else about the care continues as normal.

8. Changing Your Mind

You may withdraw this consent and revoke this authorization at any time by telling the clinician in writing. When you do, the clinician will end your child's access to Refleo. Withdrawing does not undo anything that already happened while the consent was in effect. Entries already made remain part of the record of care, which the clinician keeps for as long as state law and their licensing board require.

Parent or Legal Guardian Signature

I have read this form. I understand it. I agree to what is described above.

Signature: ________________________________________________

Printed name: _____________________________________________

Relationship to the young person: ______________________________

Email address: _____________________________________________

Date: _____________________________________________________

Young Person's Acknowledgment

To be completed by the young person where they are able to do so.

I understand that I will be recording entries about how I am doing, and that my clinician will read or listen to them. I understand that Refleo is not a person and will not answer me. I understand that if I need help right away, I should call or text 988, call 911, or tell an adult.

Signature: ________________________________________________

Date: _____________________________________________________

For the Clinician (complete only if this form was signed on paper)

I confirm that the person who signed above identified themselves to me as the parent or legal guardian of the young person named on this form, that they signed this form in my presence or returned it to me signed, and that I have uploaded a complete copy of the signed form to Refleo.

Clinician name: _____________________________________________

License type and number: _____________________________________

Practice: __________________________________________________

Date: _____________________________________________________

Form version 1.0. Questions about this form may be directed to your child's clinician, or to Refleo Health, Inc. at privacy@refleohealth.com.