Group Integration Informed Consent Form

Welcome to Integration!

Please read through the information below and feel free to ask your questions about our sessions and/or anything about us. Once you are ready to participate, please sign this informed consent form below so we will have on our records that you have read the information and that you have been properly informed about the sessions.

WHAT IS INTEGRATION?

These sessions are designed to bring people together with the shared experience of interest or actual participation in ketamine therapy. The group allows for sharing experiences, learning, and asking questions to learn how to move forward after the initial ketamine session.

We make sure to maintain a safe environment that is conducive both for sharing and accepting each other, where each can grow and trust one another and where each and everyone will feel respected and valued.

 

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;
• An act of physical or emotional abuse against a child or any person;
• Sexual abuse against a child where the child is living with the abuser;
  Whenever we are summoned by court order to disclose information against a participant. However, we shall notify you and let you exercise your privilege in the right to deny the disclosure of your records with us.
• Your prior written consent to release records.

CONDUCT AND RELATIONSHIP

For the safety it is necessary that the following is required to be complied with by its members:

1. 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;
2. Members should maintain positivity and not induce disrespect among others;
3. Members should not be drunk, nor they are allowed to take alcohol or take drugs before or after therapy;
4. Maintain conduct that brings respect to fellow members' thoughts, emotions, or behavior.
5. Refrain from having a relationship with a fellow member other than therapeutic while engaged in the session.

The Facilitator: Cory Steele

The facilitator 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 session.

WHAT TO EXPECT

The sessions consist of processing the issues that a member is involved in and the others will give their feedback and reaction towards the said issue. This helps each member understand the issue from a different perspective in order to understand others. This also helps with one's reflection about his or her situation, which can then help for insight and personal growth. There is also a format for questions and psychoeducational practices from the facilitator.

CONSENT

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