IFS Community Group Registration Form (New Dates Beginning July 26, 2024)

Welcome to your IFS Community Group! 

This document is intended to provide you with important information regarding the practices, policies and procedures of the IFS Telehealth Collective [herein called “Group Practice”], and it clarifies the terms of the professional relationship between the Group Practice, your Group Facilitator(s), and you, [herein called the “Participant” or “Responsible Party”]. It informs you about your participation in the Group Practiceʼs educational group. Please read the entire document carefully and be sure to ask your Facilitator(s) any questions or concerns you have regarding the contents prior to signing it. 

Facilitators for Befriending Ourselves: IFS Community Group: 

• Paul Ginter, Ed.D. - paul@ifs-tc.com / (269) 262-1922 
• Victoria Eagle, PsyD - victoria@ifs-tc.com / (530) 237-4222

GROUP TIMES AND DAYS 

All meetings are held online and are open to people located in the United States. Group meetings are held on the following days and times. 

Befriending Ourselves: IFS Community Group 

• Fridays, July 26, 2024 - September 13, 2024
• 105-minute sessions beginning at 10am PT /11am MT /12pm CT /1pm ET
• This group will take place via Zoom. The invitation link will be provided prior to the first meeting.

PURPOSE OF THE GROUP

Educational groups can be a powerful and valuable venue for personal growth. This group is designed to use Internal Family Systems concepts and practices to help group members establish healthier relationships within themselves, as well as with others. This is done by providing a safe and supportive environment for group members to explore their inner world, understand their parts, and promote personal growth and self-awareness.

It is the desire of your Group Facilitator(s) that you reap all the benefits the group has to offer. To help this occur, groups are structured to include the following elements: 

• A secure learning environment in which you are able to feel respected and valued as you participate in the educational group
• An understanding of group goals and group norms 
• Investment by both your Facilitators and members to produce a consistent group experience 

ATTENDANCE 

Your presence and participation in the group are important factors in its overall success. Absences have an impact not only on your personal learning, but on group dynamics and cohesion as well. Your Facilitators ask that you make attendance a top priority for the duration of the group. If you are faced with an emergency or sudden illness, please contact your Facilitator(s) using the contact information above before the group begins to let them know you will not be present. 

SUPPORTIVE LEARNING ENVIRONMENT & CONFIDENTIALITY

Creating and maintaining a supportive learning environment is a shared commitment agreed upon by the Facilitators and group members. Certain group norms will be established together, such as how members will share the space, etc.  One group agreement that all members are asked to honor is the commitment to protect each member’s identity and personal sharings by not sharing any of that information outside of the group meetings, not even with other group members.  Maintaining confidentiality in groups fosters trust and connection, and your agreement to honor each other’s confidential information is essential to the group’s success. You are welcome to share your own personal experiences about being in the group as long as it does not include information about other members. 

An exception to confidentiality would be in the unlikely event of an emergency regarding your safety, wherein the Facilitators would determine whether your emergency contact or other outside service should be consulted or engaged.  

Group members are asked to refrain from using any mood altering substances before or during the group, or otherwise attend the group in an impaired state.

OTHER CONCERNS OUTSIDE OF GROUP HOURS

Outside of group hours, should you have a medical or psychiatric emergency, or an emergency that threatens your safety or the safety of others, please call 911 or go to the nearest emergency room. In addition, the phone number for the Suicide and Crisis Lifeline is 988. Group Facilitators are only available between sessions for routine administrative and scheduling issues and are not available for on-call emergencies. 

COMMUNICATION 

You may contact your Facilitator(s) by telephone or email. Your Facilitator(s) cannot ensure the confidentiality or security of any form of communication through electronic media, including email and text messages. Communication via email or text to your Facilitator(s) should be limited to issues regarding scheduling or cancellations. While your Facilitator(s) may try to return messages in a timely manner, they cannot guarantee immediate response and request that you do not use these methods of communication to discuss content regarding support group sessions and/or request assistance for emergencies. Participants will be charged for phone calls or email exchanges of 10 minutes or longer, and the fee will be calculated at a rate of $225 per hour, prorated to the nearest 5 minute interval. 

RECORDINGS 

No audio or video recording of any kind is permitted by either the participants or the Group Facilitator(s). By signing this agreement, you agree to pay $2,500 per group session that you record without permission. Please note that in many states, all parties to any confidential conversation must give their consent to be recorded, and unauthorized recording is against the law, which means every participant present for a recording must give their prior consent. The Group Practice reserves the right to pursue civil penalties, in addition to the $2,500 per group session penalty, in the event of unauthorized recording of a session. 

FEES 

Rates for the community groups are: 

Befriending Ourselves: IFS Community Group - $700 for eight 105-minute sessions 

The fee of $700 is due at time of sign up to hold your space via credit card. Payment is required to participate in the educational group. There is a non-refundable deposit of $100, should you withdraw from the community group prior to the first session and request a refund. No refunds are given after the first session of the group or for missed group sessions.

SOCIAL MEDIA POLICY 

Your Facilitator(s) do not accept requests to connect on personal social media from Participants or representatives, such as family members. The only exception to this policy is Group Practice or Facilitatorʼs professional pages, which are open to the public. In this case, the Facilitator(s) will not directly communicate with a Participant or representative through social media. You agree not to send your Facilitator(s) messages, or to ask representatives to send your Facilitator(s) messages, through social media platforms. You should be very careful when accessing public-facing social media, and should never post any information that could be reasonably considered confidential or sensitive through Group Practice or Facilitators' professional pages. 

WHAT TO EXPECT 

Group time consists of both teaching, experiential exercises, and time to share. Sharing may revolve around an issue one member of the group is working on related to the topic of the group with time for structured feedback and reactions by other participants of the group. At times the group may focus on a topic or skill being taught with all members verbally participating. In either case, the group dynamic offers a place where you can experience support, give support, and examine your own beliefs about yourself and the world around you. These dynamics provide a very powerful environment for change. 

Although this group is educational in nature and not a substitute for psychotherapy, participants may explore various parts of themselves which may lead to emotional reactions. It is important to acknowledge that this process may evoke feelings of vulnerability, emotional discomfort, or increased awareness of challenging experiences. It is common for participants to experience ups and downs during the group sessions. Given the potential vulnerability in talking about things important to us, we seek to create an environment that is conducive to a sense of support and safety.

RISKS

Participant understands and acknowledges that, regardless of any professional licensure that a Group Facilitator may hold, IFS Telehealth Collective is not providing therapeutic services of any kind through the educational group. Through the community group, Participants will receive education to enhance their knowledge about Internal Family Systems. IFS Telehealth Collective’s staff will not diagnose any illness, disorder, or other medical condition as part of the educational community group, and Participant understands that IFS Telehealth Collective is offering the community group for informational and educational purposes only. This group is not intended as a substitute for diagnosis, medical advice, or psychological treatment. A therapist-patient/client relationship is not formed with any Group Facilitator through the Participant’s participation in the group. 

You acknowledge that your Facilitator(s) or the Group Practice does not guarantee any specific results or outcomes. You in no way shall hold your Facilitator(s) or Group Practice liable or responsible for any actions you take during or after your participation in this support group.

 

By your electronic signature of this form, you authorize charges to your credit card through Stripe via JotForm for services rendered. This authorization will remain in effect until canceled. You may cancel this authorization at any time by contacting us. You have the right to request a paper copy of this document.

In the event that your credit card information changes, you will notify the IFS Telehealth Collective immediately.

All charges will appear on your bank/credit card statement as "IFS TELEHEALTH."

In the event that you have questions, concerns, or dispute a charge to your credit card, please contact us directly.

You authorize the IFS Telehealth Collective to charge your credit card through Stripe. You also agree that your credit card can be charged for the full fee of the Community Group, in accordance with your signed Community Group Agreement.

By signing this Authorization, you are acknowledging your understanding that all payment disputes should first be brought to the attention of the IFS Telehealth Collective prior to formally disputing a charge with your credit card company. Any charges disputed with your credit card company will result in the IFS Telehealth Collective producing a copy of this signed Authorization to the credit card company (upon signature of a Business Associate Agreement) in order to recover our fees. Credit card disputes made in bad faith will result in immediate termination of IFS Telehealth Collectiveʼs services.

I confirm that all information provided is accurate, and I certify that I am an authorized user of this credit card and will not dispute the scheduled transaction with my bank or credit card company as long as the transactions correspond to the terms indicated in this authorization form.