Consent Form - all text included

How to Love Yourselfie Consent Form

Purpose of Workshop

Deepen your understanding of the media and its promotion of specific ideals of beauty.

What will I be asked to do?

This program has five (5) "selfie" modules with videos and worksheets per each module. By participating in this program, you will be asked to watch and listen to five (5) videos, read social media literacy prompts associated with each video, and then fill out the worksheets with questions provided about your experiences and reactions.

What are the risks?

We believe the risks are minimal. Nevertheless, if you find that answering any specific questions causes you concern or distress, you may skip it. If you find that several questions are distressing, communicate this to your workshop or program facilitator.

What are the benefits?

You may experience no direct benefits. However, it is possible that you learn things about media and beauty ideals that change how you think, how you react to social media messages, and some of your personal attitudes.

What if I want to withdraw from the workshop?

Participation in this workshop is completely voluntary. You are free to pause or stop at any time. If you have any questions, strong concerns or complaints about this program please contact the facilitator presenting this program to you. It could be at a school, a facility or small group setting. You will have been given the necessary information prior to starting the workbook and feel free to email Breaking The Chains Foundation at

Thank you very much for your participation!

Participants 17 years and younger, please have a parent/guardian sign/accept below.

Under 17
Sign using a mouse, stylus or fingertip, or click on the keyboard icon and type in your signature.
Sign using a mouse, stylus or fingertip, or click on the keyboard icon and type in your signature.
Date of consenter's signature.

HTLYS is developed as a prevention program to provide additional support to those who are looking for support and education around positive body image, self-esteem, and social media literacy. This program is intended to support and aid in cultivating positive and reflective conversations around body image. This program is not intended to be used in lieu of eating disorder treatment with a medical, clinical, and/or nutritional provider.

Follow up with your pediatrician or primary care doctor if you have concerns about eating disorder symptoms or treatment.

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