Dear group member and 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 both sign. 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, therefore 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 with P.A.L.S. for Healing 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.
4. Ohio law requires P.A.L.S. for Healing 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, P.A.L.S. for Healing 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, P.A.L.S. for Healing 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.
· If a group member shares certain information regarding their gender identity, Ohio law requires P.A.L.S. for Healing staff to report that information to the parent/guardian of the group member.
· 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 another group member.
5. 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.
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.
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.