Website-Adult Group Interest Form

Group Interest Form

Please note that by completing this form, it only shares your interest in a group and is not an automatic registration for the group. We will reach out to you with dates and additional information.
Which group are you interested in?*
Your Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender Identity*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your Contact Phone*
Please enter a valid phone number.
Your Contact Email*
example@example.com
Loss Information
Name of the Deceased*

First NameLast Name
Age at Time of Death*
Cause of Death*
Relationship with the Deceased*
How would you describe your Relationship with the Deceased*

Very CloseCloseNot Very CloseConflicted
Did you Attend the Funeral?*
What Race(s) do you identify with?*
What Culture(s) do you identify with?*
What are the different Community/Communities and/or Groups you belong to?*

Concurrent Issues:

	Date	Comments
Divorce/Separation
Illness/Injury
Move to New Home/School
Limited Finances
Loved Ones Death(s)
Other

Have you ever seen a private counselor or attended support group previously?*
If so, what was the reason?
Are you currently taking medications?*

Medication

	Name	Reason
Medication #1
Medication #2
Medication #3

Please list any Allergies and/or Medical Conditions
How Would You Rate Your Social Support System (ex: family/friendships/work)?*

GoodFairPoor
Additional Comments

Group Contract
Dear group member: it is necessary that you read this contract completely and understand it before signing. If you are under guardianship, you must also have your guardian sign. If you do not sign the contract you will not be able to attend the group. Thank you.

CONDUCT AND RELATIONSHIP WITH OTHER GROUP MEMBERS

No group member is ever to be humiliated or abused in any way. We encourage members to engage inactive listening, with the aim of listening for deep understanding as opposed to listening to respond.Members will be cognizant to take appropriate time in sharing their thoughts/ideas so that all groupmembers will have time to participate. Members should maintain conduct that brings respect to fellowmembers' thoughts, emotions, or behavior and respect others’ differences, religious beliefs, cultures,gender identities and sexual orientation. We are committed to embrace and celebrate diversity in all itsrichness, and to invest in creating a community based on mutual respect, understanding and openness.As a part of the group, we expect that we will support each other in the process of self-explorationaround issues of diversity and other personal difficulties, challenging our own biases and engaging incourageous dialogues for growth.

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 and no refunds will be provided. 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 with P.A.L.S. for Healing is confidential. Information shared with the group facilitators and other participants is private. There are some important exceptions to privacy listed below. In such cases I understand that my privacy rights will be waived.

·       Ohio law requires P.A.L.S. for Healing staff to report any suspected physical, sexual or emotional abuse or neglect to appropriate agencies.
·       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 you about the order. If you 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, grant reporting, and published newsletters. I understand that my name and face will not be used.
·       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.

· I understand that I may participate in therapeutic and/or movement during sessions. I will participate when able and accomodation can be discussed prior. I release all liability of P.A.L.S. for Healing for any injury I may incur.

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 personnel and P.A.L.S. for Healing representatives regarding pertinent issues in order to provide continuity of care.

6.         I agree that my 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 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, and I have read and understand the information listed in the group contract. I fully understand and agree to participate as I am able and release P.A.L.S. for Healing.
Relationship to Potential Group Member*
Your Name*

First NameLast Name
Your Date of Birth*

MonthDayYear
Date
Your Signature*

Clear
Today's Date*

MonthDayYear
Date
Should be Empty:

Group Interest Form

Group Contract