Group Therapy and Workshop Consent Form
Please read through the information below and feel free to ask any questions by emailing info@healthintandem.com. Once you are ready to participate, please sign this informed consent form below indicating that you have read the information and are properly informed about group therapy and/or workshops. For simplicity, all group services will be referred to as “group” unless otherwise specified.
Confidentiality
Confidentiality is a collective responsibility of all group members and facilitators, and is a necessary commitment for continued participation in the group. Your group facilitators are ethically and legally bound to maintain your confidentiality and will not release your information to anyone outside of Health in Tandem (HiT) without your written permission. Legal and ethical exceptions to confidentiality include: 1) being in imminent danger of harming yourself or someone else; 2) knowledge or suspicion of current and ongoing child abuse or dependent adult abuse; and 3) legal mandates, such as subpoenas or court orders.
While group facilitators are legally and ethically required to maintain your confidentiality, except as required by law, group facilitators cannot guarantee that other group members will not share your information with others. Thus, confidentiality among group members is based on mutual trust and respect. Group facilitators may consult with other HiT clinicians or supervisors as part of ethical and professional practice. Identifying information will be shared only as necessary and within confidentiality guidelines. By signing this form, I agree to maintain the privacy of my fellow group members. This includes, but is not limited to, names, physical descriptions, medical information, and specifics of the content of interactions with other group members.
Technology
HiT uses Simple Practice for some group services. Our version of Simple Practice meets Health Insurance Portability and Accountability Act (“HIPAA”) standards of encryption and privacy protection, but we cannot guarantee privacy. In order to participate in group teletherapy, you must have access to the following: 1) a secure and stable internet connection; and 2) a laptop, computer, tablet, or mobile device capable of videoconferencing. In addition, we ask that you keep your camera turned on for the duration of each group session, unless you need to step away temporarily (e.g. use the restroom). Recording of group sessions is prohibited.
Additional Responsibilities as a Group Member
Privacy: For teletherapy groups, you must have access to a private and quiet space for each group session in order to maintain privacy and minimize interruptions. It is crucial that no one is within close visual or hearing proximity to you during group sessions.
Commitment: Participation in group requires a strong and steady commitment to ensure cohesiveness. With this in mind, we ask you to agree: 1) to attend weekly (when in a closed group); 2) to prioritize group sessions in your schedule; and 3) to notify group facilitators about your absence as soon as you are able.
Punctuality: Group will start and end on time. Your punctuality is crucial to group running smoothly, so please arrive on time and stay the entire session.
Engagement: Your facilitators and fellow group members expect your full participation and engagement during group. This helps ensure that group feels safe and supportive for all involved. Please silence or turn off your cell phone and minimize other distractions (e.g. schoolwork, social media, email, etc.) while you are participating in group.
Goals and Participation: Your group facilitators are happy to collaborate with you to develop appropriate therapeutic goals for your group therapy experience. You are in control over how much you speak or share with the group.
Eating and Drinking: You may bring food or drink to group sessions as long as the group is not distracted by the behaviors around said food/drink. You agree to attend group sober and do not use drugs or alcohol during the group session.
Evaluations and Feedback: In order to improve and grow our group therapy program, we will ask you to complete an anonymous evaluation at the conclusion of group. While your completion of this evaluation is voluntary, we greatly value your feedback. Information provided in these evaluations is de-identified, aggregated, and reported to the Clinical Director of HiT.
If You are in Crisis
Group is not a replacement for individual therapy, if needed, and it is not appropriate for emergency or crisis care. If you are feeling suicidal or in need of extra support, please share with your group facilitator afterwards. If you are in need of support in between groups, you can call HiT (708-320-9679) to request a crisis session with a therapist. After hours, you can connect to the Suicide and Crisis Hotline at 988, call 911 or go to your local emergency room.
Right to Remove a Group Member: Group facilitators reserve the right to remove a participant from the group if participation is deemed clinically inappropriate, disruptive, unsafe, or in violation of group agreements, including confidentiality or substance use expectations.
By signing this consent form, I understand and agree to the following:
I understand that participation in group therapy and/or group teletherapy involves inherent risks, including but not limited to emotional discomfort, distress, or interpersonal conflict that may arise from discussing personal experiences in a group setting. I acknowledge that these risks are a normal part of the group psychotherapy process and that participation is voluntary.
I understand that due to the nature of the session, HiT cannot guarantee that information shared in the group therapy and/or group teletherapy sessions will be kept confidential.
I understand that group teletherapy services are provided in accordance with Illinois licensure laws, and I agree to participate in group sessions only while physically located in a state where the group facilitator is legally permitted to practice.
I will not record (video, audio or screen shot) any portion of the group therapy and/or group teletherapy sessions and understand that doing so is strictly prohibited. I understand that I may be dismissed from the group for doing so.
I agree to maintain the confidentiality of other group members. I will not disclose names or other identifying information about group members and will not discuss personal issues or experiences of other group members or share this information on any social media.
I agree that I will not post information or pictures that name or show any group members on social media.
I have carefully read, understand, and agree to all of the conditions contained in this Consent Form.