Group Therapy Registration Form
  • Group Therapy Registration Form

  • Welcome to our Group Therapy Registration! Please read through the information below and feel free to ask your questions about our lessons and/or anything about us. Once you are ready to participate, please sign the advisement form below confirming you have read the information and that you have been properly informed about the class.

  • CONFIDENTIALITY We respect each and everyone's right to privacy and confidentiality and we shall make sure to maintain it that way. However, please understand that this is not absolute and is limited to provide for by law. Certain limitations are as follows: Threatening one's self or another that may result in physical harm or death; An act of physical or emotional abuse against a child or any person unable to independently care for self; Sexual abuse against a child where the child; or discovery that a child is living with a registed sex offender.

    NO SHOW/ CANCELLATION POLICY Horizon Family and Community Services has adopted the following policy regarding No Shows and Cancellations. Cancellations must be 24 hours advanced notice. Calling after your missed appointment time amounts to a No Show. If you have a standing appointment time and you No Show you will need to confirm the next scheduled appointment, or your appointments will be cancelled until we hear from you. We cannot guarantee that you will get your same appointment time back. Remember it is important to notify us of any changes. 

    FEES AND PAYMENT FOR SERVICES - Your class fee will be discussed with you during your initial intake. If your group class has a fee, you may be billed either through our Therapy Notes program or our Quickbooks system. All invoices will need to be paid before your class.

    You will be responsbile for the full session fee if you:

    • No-Show and Late Cancellation Fees
    • Full payment is due before your class begins. If you are unable to pay, tell your instructor. 
    • Your Instructor may charge administrative fees for writing a letter or report at your request; consulting with another healthcare provider or other professional outside of normal case management practices; or for preparation, travel, and attendance at a court appearance. Fees for such services vary, but range from $45.00 to $150.00 an hour. Payment is due in advance. A letter of completion is included and does not have an extra fee. Some classes are free for current clients.

  • CONDUCT AND RELATIONSHIP If you are in a group session, for the safety it is necessary that the following is required to be complied with by the members of the group: Discussions made within the group session are not allowed to be discussed outside with anyone and should maintain the practice of confidentiality in order to build trust with fellow members; Members should maintain positivity and not induce disrespect among others; Members should not be drunk, nor they are allowed to take alcohol or take drugs before classes; Maintain conduct that brings respect to fellow members' thoughts, emotions, or behavior. Refrain from having a relationship with a fellow member other than professional while engaged in the class.

     

     

  • The Instructor(S) The instructor should maintain a professional relationship with the participants all the time and no more than that. Any relationship with a participant may result in a "dual relationship" and may affect the goals of the group classes.

  • Acknowledgment  I agree to adhere to the norms and expectations for group classes as indicated above. I acknowledge that I have had the opportunity to ask questions and such questions were answered clearly and to my satisfaction.

  •  -
  • Clear
  •  - -
  • Should be Empty: