As a group member, I have rights and benefits as well as duties, and I understand that some of them are described in this agreement. 

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This group will be called The Heroes’ Armor and will meet from October13, 2023 to November 17th, 2023 on Fridays from 2-3pm. The group is donation based (pay what you can) for anyone who is not a current client at Emerge Counseling & Art Therapy.  The recommended amount is $35 per group.

 

If you have an open claim with Provident, we will bill $65 per group, which may or may not be paid in full by Provident.   As with individual therapy, we will be required to submit clinical documentation of your participation in group in order to bill Provident.  Please direct any questions or concerns to Ashton Sullivan.

 

The purpose of this group is to provide you with the opportunity to achieve the following goals: 

 

1.  Increasing peer support

2.  Decreasing stigma in the work environment

3.  Decreasing avoidance, suicidality, depression, self-medicating, and relationship failures

4.  Increasing resilience

5.  Recognizing signs of post-traumatic stress in yourself and in peers

 

I agree to work in this group. This means openly talking about my thoughts and feelings, being honest and respectful, keeping my promises, and exchanging helpful feedback with other members of the group. 

 

I will attend group meetings that I signed up for from start to finish, even if I do not always feel like it. If I cannot attend, I will tell the group at least 24 hours’ in advance, or, if it is an emergency, contact the leader (Ashton Sullivan) as soon as I know I cannot attend. If I decide not to go on or am unable to go on with the group, I will discuss my reasons with the leader, and I will give honest feedback. 

 

I will not form confidential relationships with other group members or leaders outside the group. This is needed so that everyone will be equals in the group, and that the group can stay focused on its goals.  I will not cross talk in the group (engaging in a closed conversation with another participant that excludes other group members).

 

I understand that this group experience is not a replacement for individual therapy. If issues arise that are not suit­able for the group’s process, I may benefit from individual therapy sessions, for which I will have to pay separately from the cost of the group therapy. I will discuss this with the group’s leader(s). 

 

I understand that the leaders are required by law to report any suspected child or elder abuse, or serious threats of harm to myself or another person, to the proper authorities. 

 

With full understanding of the need for confidentiality (that is, privacy) for all group members, I accept these rules: 

 

1. We will use only first names. I promise to tell no one the names of the group members, or in any other way allow someone not in the group to learn their names. 

 

2. We will permit no children, spouses, journalists, or other visitors in our sessions. 

 

3. We will not permit any kind of recordings of our sessions, even by our members or leaders. 

 

4. I promise not to tell anyone outside the group about any of the problems, history, issues, or other facts presented by any group member, even if I conceal the name of the member. 

 

5. I understand and agree that if I break rules 1–4 often without meaning to, or if I ever break one of these rules on purpose, I will be asked to leave the group. I will also face a possible lawsuit in which I may have to pay damages. If I reveal private information, I give the offended person or persons the right to recover for damages to his, her, or their reputation. Also, this person or persons may recover for any other damages that can be proven. 

 

6. I understand and agree that the leaders may keep a clinical case record on each individual member, and that this record will not contain information by which any other members can be identified. This record, kept in each member’s name, can be shared with other professionals only with the member’s written con­sent or to meet legal requirements.

 

7. I understand that the leaders may keep another record about the group’s meetings and the interactions of the members, and that this record will not be included in any member’s records. This record may not be shown to anyone without the written agreement of all the members and the leaders. 

 

I have read, understand, and agree to the points stated above, as indicated by my signature below.