Informed Consent for Group Therapy Session
Presented by:
Self-Care Alignment & Awareness Nest, LLC (SCAN)
In partnership with
Chicago Christian Counseling Center (CCCC)
Unmasking Stress: Identifying Hidden Burnout Before It Shows Up
Date & Time: Saturday, October 25, 2025 | 1:00 PM – 3:30 PM
Location: Chicago Christian Counseling Center – 15127 73rd Ave, Suite G, Orland Park, IL
Facilitator: Asia S. Foster, Clinical Intern & Dr. Timothy M. Jones Sr.
Site Supervisor: Heather Mulcahy, LCPC (Chicago Christian Counseling Center)
University Supervisor: Dr. Danette Buchanan, Liberty University
Purpose of the Group
This group session is designed to help participants increase awareness of stress and burnout, recognize early warning signs, and learn effective strategies for self-care and emotional regulation. Participants will engage in guided discussion, self-reflection, and mindfulness-based practices such as grounding and deep breathing.
This session will be facilitated from a Christian/Biblical foundation, integrating faith-based principles that promote holistic wellness; mind, body, and spirit. The group welcomes all participants and maintains an environment of inclusivity, compassion, and respect.
While this session draws on therapeutic and clinical practices, it is not a substitute for individual psychotherapy. Participants are encouraged to seek personal counseling for deeper emotional needs as appropriate.
Nature of Group Participation
The group will meet once for a 2.5-hour session.
Activities include short educational teachings, open discussions, reflection exercises, and relaxation techniques. Participants are encouraged, but not required, to share personal reflections. The group will operate in a supportive, faith-centered, and educational environment.
Confidentiality
Confidentiality is an essential part of this group experience. All members are asked to respect one another’s privacy and keep all shared information confidential.
However, the facilitator and supervisors are legally and ethically required to break confidentiality if any of the following occur:
- There is reason to believe a participant may harm themselves or others.
- There is disclosure or suspicion of child, elder, or dependent adult abuse.
- Information is required to be released by law or court order.Please note: Confidentiality cannot be guaranteed among group participants, so it is encouraged to use discretion when sharing personal information.
Recording & Supervision Disclosure
This group session will be recorded for educational and supervision purposes.
By signing this form, you acknowledge and agree to be recorded. You understand that:
- The recording is required for Liberty University’s Clinical Mental Health Counseling Master’s Program as part of the facilitator’s internship coursework.
- The recording will be reviewed only by the facilitator’s Site Supervisor (Heather Mulcahy, LCPC) and University Supervisor (Dr. Danette Buchanan, Liberty University) for supervision and evaluation purposes.
- The recording will be securely stored, not shared publicly, and permanently deleted after meeting supervision and program requirements.
- Voluntary Participation & Right to Withdraw
Participation in this group is completely voluntary. You may choose to withdraw or decline to participate at any time without consequence. If you decide to leave early, please notify the facilitator.
Potential Benefits & Risks
Potential Benefits: Increased self-awareness of stress and burnout warning signs.
Learning practical self-care and grounding strategies.
Strengthened faith-based insight and connection to self and others.
Potential Risks: Reflective activities or discussions may bring up emotional discomfort or awareness of deeper issues.
Vulnerability may arise when discussing personal experiences in a group setting.
The facilitator will offer support and referrals for additional care if needed.
Consent Statement
By signing below, I acknowledge that I have read and understood the information provided above. I understand the purpose, process, and potential risks and benefits of this group. I voluntarily agree to:
- Participate in the group session.
- Be recorded for educational and internship supervision purposes.
- Maintain confidentiality and respect the privacy of other participants.