Consent For Group Treatment

About Group Therapy

Group therapy may help individuals work through their problems by interacting with a counselor and other individuals who are facing similar struggles. Group participants share their personal experiences, feelings, and struggles, and receive and provide support

Personal Commitment to the Group

I understand that my attendance and participation are necessary to create an environment of growth. I understand that I am expected to treat everyone in a group with respect in order to contribute to a safe environment. I commit to maintaining my fellow group participants' confidentiality. While I may share my personal experience from a group outside of the group setting, I will do so without compromising my fellow group participants' confidentiality nor will I share the content or experiences of my fellow group participants. I commit to keeping my fellow group participants' names and identities confidential.

If I am unable to attend a group session, I will contact the group facilitator within 24 hours of the scheduled session. If I am unable to attend due to an emergency, I will contact the group facilitator as soon as possible. If the group is on a monthly fee schedule, I will be charged for the whole month even if I am unable to attend every session for that given month.

Fees

All group sessions are scheduled for 90-minutes and meet on a weekly basis, unlessarranged otherwise by the group facilitator. I am financially responsible for payment infull at the time services are rendered and, by submitting this form, confirm that I haveunderstood any fees associated with participation in this group. If the group is provided at no-cost, I understand that attendance and participation remain imperative.

 

Limits of Group Therapy

While I can expect many benefits from group therapy, such as symptom management orresolve, support and encouragement, counsel and guidance with the human thought andemotional process and in some cases the neurobiology of such, I fully understand thatbecause of factors beyond our control such benefits and particular outcomes cannot beguaranteed. I understand that because of the counseling I/he/she/they may experienceemotional strains, feel worse during treatment, and or may make life changes whichmay be distressing. I understand that group therapy is not a substitute for in-person individual counseling.

Confidentiality

While the group facilitator will keep my treatment confidential, unless in the case of the exceptions listed below, I understand that the group facilitator cannot guarantee that the group participants will maintain confidentiality. I understand that the group participants are not obligated to the same ethics and laws as the group facilitator.

I understand the conversations with the group facilitator will be confidential except as allowed by Privacy Policy (HIPAA).  I understand there are limits to confidentiality based on payment methods, as well as wireless and electronic communication that I elect to utilize.   I further understand that in Florida, law requires that any psychotherapist who has reasonable cause to suspect child or elder abuse, neglect, abandonment or exploitation to report such knowledge to appropriate authorities.  I also understand that Florida law allows the confidentiality between client and therapist to be waived when there is a clear and immediate probability of physical harm to the client or to other individuals or society.  The group facilitator is mandated to communicate the information only to the potential victim(s), appropriate family members, law enforcement or other appropriate authorities.

If I wish to have any information shared regarding my treatment, I must have a signed release of information on file.  While parties may communicate with this practice information regarding myself, my group facilitator will not confirm or deny any relationship with myself.  Information will not be shared or exchanged without a signed release of information.  If my treatment involves a partner, spouse, family members or other legal adult, no information will be released without written consent of all parties.  I can expect my legal rights to be protected.

I understand that my group facilitator cannot provide emergency service at any time, and I have been informed to call 9-1-1 or 9-8-8 in an emergency during business hours, evening hours and on weekends.  I understand the group facilitator is a professional resource only.  The group facilitator’s interventions may be freely accepted or rejected by the client. Therefore, decisions made by the client during and or after counseling is the responsibility of the client.  I understand that regular attendance will produce maximum benefit but I have also been informed that as a voluntary client I can discontinue treatment at any time.

I understand that my group facilitator or care coordinator may wish to send appointment reminders via text or email.  The confidentiality of this communication cannot be guaranteed.  If I wish to communicate only through encrypted HIPAA compliant texting and email it is my responsibility to communicate this with my group facilitator at the time of initiating treatment. I understand that my group facilitator will not accept friend requests or engage in personal social media communication. This denial is a reflection of the highest standard of professional ethics and is not a reflection of anything else.   I am free to engage with my group facilitator or Boundless Hope LLC staff via professional social media pages at my own risk. 

If at any time, my group facilitator experiences an emergent incapacitation, I consent to a colleague accessing my contact information to cancel or reschedule my services.

I understand that if I see my group facilitator in public, they will not initiate contact with me.  If I choose to do so, my group facilitator will respond on the level of relationship based on my lead.

I understand if I participate in electronic treatment provided by a HIPAA compliant format, that the treatment provided can be limited by what the group facilitator can observe in limited view. It is my responsibility to ensure the confidentiality of my setting if I am participating in telehealth. I understand there are circumstances where a group facilitator will not recommend and may choose to not participate in telehealth due to limited ability of assessment, risk of safety or other purposes per their clinical judgment.

Procedures

I understand at any time my group facilitator feels that my best client care cannot be provided by themselves, they may discontinue treatment. I can expect that, upon my request, that my group facilitator will provide referrals.

I understand it is counter-therapeutic to attend appointments under the influence. If my group facilitator discerns this has occurred, in their professional judgment, they may terminate the appointment early and I should expect to be financially responsible for the entire group session/month.

I understand that if I need any documents to be produced by this office, I may be required to pay the provider’s private pay rate per session.  The total amount depends on the time required to prepare and process such documents, with a minimum of one session billed.  If you or another party requests a copy of medical records, a treatment summary will be provided.  You can expect a professional document provided in a reasonable amount of time.  The release of medical records also requires a signed release of information.  Additionally, I understand that if I have voluntarily interrupted services, and wish to come back to therapy I have to have at least 4 sessions prior to the group facilitator providing such documents.

I know of no reason I/he/she/we/they should not participate in therapy and I/he/she/we/they agree with all the terms of this consent and agree to participate fully and voluntarily. 

I have been offered the Notice of Privacy Practices (HIPAA) and have read it and discussed any questions I may have with my group facilitator.  I understand and agree this consent will remain valid subsequent to my reading the HIPAA unless I advise otherwise.

A habit of no-show appointments may result in my group facilitator discharging me from their care.  Referrals can be provided upon your request. 

Should I arrive tardy to an appointment, my appointment will still end at the scheduled time to ensure punctuality for the remaining clients.

 Depending on the nature of the group and the credentials of the facilitating clinician, some groups may be self-pay only while others may be eligible for billing through insurance. If I choose to use insurance, I understand that it is up to me to provide the information necessary for the submission of claims, confirm the facilitating clinician is in-network with my plan, and verify that group counseling is a covered service under my insurance plan. If I  choose to pay for services using a health/flexible savings account or out of network coverage, it is completely up to me to ensure my insurance provider validates this.  I understand that myy insurance company will often require a mental health diagnosis  if I choose to use my benefits and that this diagnosiswill enter into the medical chart.

Any parent/guardian who signs this form for a minor dependent is financially responsible for any services rendered to that minor.

Postdated checks cannot be accepted. There will be a $35 fee charge for any returned checks plus any additional bank charges.

(or person authorized to consent for client)