Collective Member Interest Form 2 2

Name

First Name

Last Name

License Type

Which membership type are you interested in?

Learn more about membership types:

Tier 1

Tier 2

Tier 3

Other/Undecided

Please share with us more about your practice

Why are you interested in joining a collective structure?

How do you align with our shared values? (Trauma-Informed, Identity-Affirming, Relational, Systemic)

Anticipated starting date

YYYY

Anything else helpful for us to know?

MIDDLEGROUND MENTAL HEALTH COLLECTIVE, LLC

COMMUNITY MEMBER AGREEMENT

EFFECTIVE NOVEMBER 1ST, 2025

As a condition of your participation in and/or access to Middleground Mental Health Collective, LLC (“Middleground”) community meetings, events, and other offerings, you agree to the following terms and conditions.

1. Accuracy of Information

Members must maintain accurate and up-to-date information in their member directory listing. If any license, insurance, or practice information changes, members are required to notify Middleground in writing and update their information within ten (10) business days of the change.

2. License and Liability Insurance

Members must provide Middleground with a copy of their active professional license and current professional liability insurance policy (or certificate of insurance). Middleground may request updated documentation at any time to verify continued eligibility for membership.

3. Professional and Ethical Standards

Members must abide by all professional, legal, and ethical standards applicable to their discipline and licensure. All members are expected to demonstrate professionalism, integrity, and respect in all Middleground spaces, both in person and online.

4. Use of Facilities and Equipment

When attending community meetings, events, or using Middleground facilities or virtual platforms, members must exercise due care and caution. Members are responsible for any damage or destruction caused by their actions. This applies to both physical spaces and virtual tools or platforms provided by Middleground.

5. Lawful and Respectful Conduct

Members must not engage in any illegal or unethical activity in connection with Middleground. Members must also refrain from any behavior that could reasonably bring disrepute to Middleground or its members.

6. Guests and Invitations

Members may not invite or admit any non-member to Middleground community events, meetings, or other offerings, whether in person or online, without prior written approval from Middleground.

7. Respectful Participation

Members shall not engage in any behavior that interferes with or disrupts the use and enjoyment of community offerings by others, causes nuisance or annoyance, or results in loss, damage, or increased risk to Middleground (including damage to its reputation).

8. Confidentiality and Privacy

Members shall not disclose or share any confidential or client-identifying information in any Middleground community setting, online forum, or presentation. If a member is a “Covered Entity” or “Business Associate” under HIPAA, they are responsible for maintaining HIPAA and HITECH compliance, including all applicable privacy and security safeguards.

9. Non-Solicitation and Marketing

Community spaces, events, and directories may not be used for solicitation of clients, marketing of products, or recruitment of business unless expressly authorized by Middleground.

10. Anti-Harassment Policy

Middleground is committed to maintaining a harassment-free and inclusive environment. Discrimination, harassment, or bullying of any kind

11. Membership Term and Renewal

Memberships automatically renew on a month-to-month basis unless terminated by either the member or Middleground. Members may cancel their membership at any time by providing written notice to Middleground.

12. Revocation of Membership

Middleground reserves the right to revoke or terminate membership at any time, at its sole discretion, including but not limited to the following reasons: Violation of ethical, professional, or legal standards; Conviction of a serious or egregious crime; Unprofessional or inappropriate conduct; Hostility toward other members or community participants; Misuse of space, resources, or platforms; Conduct detrimental to the reputation or mission of Middleground.

13. Amendments to Terms

Middleground may modify, amend, or supplement these terms from time to time for the benefit and safety of the community. Updated terms will be communicated to members and become effective upon notice.

14. Limitation of Liability

To the maximum extent permitted by law, Middleground and its owners, employees, contractors, and agents shall not be liable for any indirect, incidental, special, consequential, or punitive damages arising out of or related to membership participation, events, or community activities. Members expressly assume all risks associated with participation in Middleground activities, including both physical and virtual engagements.

15. Governing Law and Venue

This Agreement shall be governed by and construed in accordance with the laws of the State of Texas, without regard to its conflict of laws principles. Any dispute arising under or in connection with this Agreement shall be brought exclusively in the state or federal courts located within Travis County, Texas, and the parties consent to the personal jurisdiction of such courts.

16. Acknowledgment of Agreement

By purchasing a membership through Middleground Mental Health Collective, LLC’s website or payment platform, the member acknowledges that they have read, understood, and agree to be bound by all terms and conditions set forth in this Member Agreement. Completion of the membership purchase constitutes the member’s electronic signature and consent to these terms.