Clone of Group Session Sign-Up

Women's Relationship Support Group

Registration: Group Starting November 8th @11:00am
Name

First NameLast Name
Complete if not a HMHS Client
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail Address
Don't forget your email! :)
Phone Number

Area CodePhone Number
Date of Birth

MonthDayYear
Insurance
Insurance Type
Insurance Member Number

Confidentiality Statement

PLEASE READ & SIGN
Confidentiality Statement
Creating a safe and supportive environment is essential to the success of this group. To protect the privacy and well-being of every participant, we ask that all members commit to the following confidentiality agreement:

What is shared in the group stays in the group.
Personal stories, experiences, and emotions shared by group members must not be repeated, discussed, or disclosed outside of the group setting—this includes family, friends, and social media.
Respect each other's privacy.

Please do not ask other group members to share more than they feel comfortable. Everyone should feel empowered to speak at their own pace.

No screenshots or recordings.

For virtual sessions, participants agree not to take screenshots, record audio or video, or share any content without the explicit permission of the group facilitator and member(s) involved.

Confidentiality has limits.

As a licensed clinical social worker, the group facilitator is legally and ethically obligated to break confidentiality if:

A group member is at imminent risk of harming themselves or others
There is suspected abuse or neglect of a child, elderly person, or vulnerable adult
A court order mandates disclosure

By participating in this group, you acknowledge and agree to uphold these confidentiality guidelines to ensure a safe space for healing, growth, and trust.
By Signing this Document You agree to adhere to the confidentiality of the group

Clear

Should be Empty:

Women's Relationship Support Group

Complete if not a HMHS Client

Confidentiality Statement