Dear group member and/or parent/guardian: it is necessary that you read this contract completely and understand it before signing. If you are under the age of 18 you must also have your parent/guardian sign as well. If you do not sign the contract you will not be able to attend the group. Thank you.
1. I understand that regular attendance is required for me to get the full effects of the healing process. As the content and relationships with other group members builds from week to week, I understand that if I miss more than two sessions I may be dropped from the group. I understand that I am agreeing to attend the entire series.
2. I agree that what is spoken by myself and the participants of this group is confidential, and I should not talk about other group member’s personal information outside of group.
3. I understand that my group work at Cleveland School of the Arts in association with P.A.L.S. for Healing and Say Yes Cleveland is confidential. Information shared with the group facilitators and other participants is private. I understand that parents/guardians have legal rights to information discussed in group pertaining to their child. There are some important exceptions to privacy listed below. In such cases I understand that my privacy rights will be waived.
· Ohio law requires Cleveland School of the Arts in association with P.A.L.S. for Healing and Say Yes Cleveland staff to report any suspected physical, sexual or emotional abuse or neglect to social services.
· If a person expresses intent to bring harm to him/herself or other, Cleveland School of the Arts in association with P.A.L.S. for Healing and Say Yes Cleveland reserves the right to inform other family members, and/or make appropriate referrals if necessary, including the police.
· If information is ordered by the court, including a subpoena, Cleveland School of the Arts in association with P.A.L.S. for Healing and Say Yes Cleveland will attempt to contact the parent/guardian about the order. If the parent/guardian opposes the release, the court may require compliance with the order.
· At times, P.A.L.S for Healing staff members may use case examples of group members, including artwork, for educational training, fundraising efforts, and published newsletters. P.A.L.S upholds confidentiality and will not use names without written consent.
· P.A.L.S. for Healing will encourage confidentiality among group members, however, P.A.L.S. for Healing cannot be responsible for any breach of confidentiality by a group member.
4. In order to create a safe and supportive environment, I understand that expressing inappropriate and/or disruptive behavior may cause me to be dismissed from the group and as a group member I will not relay information shared by group members outside of the group.
5. I authorize the exchange of information between appropriate school personnel and P.A.L.S. for Healing representatives regarding pertinent issues in order to provide continuity of care.
6. I agree that my child’s artwork, photographs or representations may be used in future educational training, display and/or publication by P.A.L.S. for Healing. I understand that my child’s name and/or face will not be used in conjunction with any presentation or discussion of the work.
7. I understand that in cooperation with the school guidance counselor, principal, or other appropriate personnel, my child will be seen at school by a trained and qualified professional from P.A.L.S. for Healing.
8. I authorize the exchange of information between the appropriate school personnel and P.A.L.S. for Healing representatives regarding pertinent issues.
In signing this document, I acknowledge that I have had the opportunity to ask questions regarding this confidentiality policy. I have read and understand the information listed in the group contract. I fully understand and accept my rights to privacy and the exceptions to privacy listed on the front of this form.