Group Consent Form

This document is intended to provide important information to you regarding your treatment. Please read the entire document carefully and be sure to ask the group facilitator any questions that you may have regarding its contents.

 

A telehealth support group adds some unique challenges and situations that are addressed
in this form. In order for group to work well, a safe environment must be created and
maintained. The first step towards creating a safe environment is for you to understand and
agree to the following guidelines:

 

Confidentiality
Information shared in group will be treated with the same type of confidence as individual
session by the group facilitator. Information will not be released without your expressed
permission. Exceptions to confidentiality are the same as those for individual session and are
as follows:
1. Disclosure is required by law when there is reasonable suspicion of abuse of
children, elderly persons, or dependent adults; or where the client presents a serious
danger of violence to another.
NOTE: Reasonable suspicion of child abuse includes knowingly preparing,
selling, accessing, streaming, downloading, viewing, and/or distributing material
of a minor engaged in an act of obscene sexual conduct, including ”sexting.”
2. Disclosure is permitted by law allowing protective measures to be taken if I am likely
to harm myself.
3. There is a court order issued from a judge to release mental health records.

While the group facilitator has legal and ethical mandates and guidelines to maintain confidentiality, a group member does not. Thus, it is imperative that all group participants commit to keeping identifying details of fellow group members confidential in order for the group to be a safe space for participation and disclosure.

 

Your group facilitator will use a HIPAA-compliant platform from a secure internet connection to
protect the confidentiality of group members. Group members are responsible for the following:
1. Be in a private setting, alone with the door closed.
2. If possible, wear headphones to better protect the privacy of other group members.
3. Use a secure Wi-Fi/Internet connection rather than public or free Wi-Fi.
4. Should someone enter the room you are in, alert the group immediately, cover your
screen and mute your volume. If the disruption is not brief, you may need to exit the
group until you are alone again. If you are unable to return to group, please send a
secure message to the group facilitator to inform them of the reason you were unable to
return to group.
5. Recording of sessions is NOT permitted.

By joining the group, you are agreeing that you are in an environment where others cannot overhear the group's dialogue or see your screen. If the group facilitator notices that non-members are visible or audible during the session, they will ask you to secure your environment and/or leave the group until privacy can be attained. The group facilitator reserves the right to remove you from the group, if you do not do so yourself. If you are removed, the group facilitator will check in with you after the session ends.

 

Group Member’s Agreement for Confidentiality
All members of the group will be asked to agree to a high level of confidentiality in the group sessions. This means that each participant agrees not to share any other group member’s identifying and personal information with others. It is appropriate to share your personal reaction and feelings about group with others, but please do not share other people’s stories with anyone outside of the group.

 

Online Reviews and Social Media
We understand that the use of the Internet, online reviews, and social media impact virtually all aspects of our lives. Please be aware of the implications of posting information about your group sessions online! Please consider any potential negative impact that this could have either today or in your future.

Benefits and Risks
Group telehealth can have many benefits such as providing a space to share your personal experiences, giving, and receiving support/constructive feedback, and experimenting with new
interpersonal behaviors. While there are benefits to group telehealth, video platforms pose more risks and challenges than in-person groups, which can impact group member's confidentiality and comfort. Group facilitators' lack of control over group members' environments is an inherent risk of online group session despite attempts to ensure privacy (see Confidentiality section above). If you have concerns about confidentiality, you are encouraged to discuss your concerns with the group facilitator and group members; please voice your concerns before leaving a session so the group can make adjustments. You may choose to leave a particular group session or the group altogether; please communicate your decision to the group facilitator.

Additional challenges to a telehealth format that may create discomfort include technology issues that result in lag time or loss of internet connection and the loss of non-verbal cues and room for misinterpretation by group leaders and group members. Please clarify with group leaders and/or members if you feel misunderstood.

 

Attendance and Timeliness
Group members are expected to sign on to the video platform 5 to 10 minutes before the start
time and stay throughout the entire session. Your early arrival ensures that the group is able to
start on time, and provides time to trouble shoot if technical issues arise. If you are unable to
attend a session, please contact your group facilitator prior to the meeting.

Active Participation/Avoiding Distractions
You are encouraged to freely and openly share your concerns, as well as experiences,
feelings and reactions with the group. You will discuss as a group how best to identify that you
need time to talk during the group to avoid interrupting others.
Please keep in mind the following considerations so you and others can feel your "presence" in
group:
1. Connect with both video and audio, unless you make prior arrangements with your
group facilitator.
2. Do your best to eliminate distractions and interruptions: silence phone calls, text
messages, emails, and other notifications; put a "do not disturb" sign on your door,
remove pets from the room.
3. Look at the screen/camera to show you are attentive; stay focused on group
interactions.
4. Use gallery view so you can see the faces of all participants.
5. Suggestions for being fully present in group (if possible): sit at a desk with your device
at face level; use a tablet or computer rather than a cell phone; and/or sit with a light
source behind your camera so your face is visible.

 

Crisis Management and Intervention
What constitutes an emergency is at the discretion of the group facilitator and includes but is not
limited to becoming incapacitated during the course of a session and/or expressing harm to self or others when your group facilitator is unable to reach you for further assessment. If you are having thoughts of suicide or are unsure of your ability to maintain the safety of
yourself or others, you agree to utilize crisis services instead of attending the group visit. To be connected to a counselor during regular business hours, you can call the main line at SPS.
For 24/7 crisis support, you can call the National Suicide Hotline at (800) 784-2433. If you need immediate attention and/or your concerns are life-threatening, please call 911 or go to the nearest emergency department

 

Fees
The fee for each group session is $40 and $320 total. Payment is requested at the beginning of 8-week group sessions. If you do not stay in the group for the full 8 weeks a refund of the remaining time will be given back to you. Payment can be made by debit or credit card, PayPal by using the website checkout.

 

Contacting Group Facilitators
If you need to contact the group facilitator between group sessions, please call the group facilitator at (510) 399-5309 during regular business hours (Mon-Fri 5pm – 8pm). You can also email the group facilitator at ronica.clark@getpeaceofmindtherapy.com and they will replied by the next business day.

Consent
I have read and understood the information provided above, and agree to abide by the
guidelines for participation in group telehealth. I am satisfied that I have had
opportunity to have any questions or concerns addressed by my mental health
provider. By submitting this document, I agree to abide by its terms.