ICW Caregiver Support Group
Please sign up your participant here for the Caregiver Support Group at ICW. Friday, May 1st 6 -7:30 PM.
Caregiver Full Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
MUHSEN Caregiver Support Group — Expectations I agree to adhere to the following norms and expectations of the MUHSEN Caregiver Support Group:I will not discuss anything shared in the group with others outside of the group.I will be respectful of others’ thoughts, emotions, and behavior.It is essential that members understand that whatever they say or how they act in the group remains confidential. Members agree not to discuss these matters with anyone outside the group. This confidentiality helps create a safe and inclusive space where members can trust one another.Exceptions to confidentiality:Facilitators may be required by law to disclose confidential information without permission in the following circumstances:Indications of harm to self or othersAwareness of harm being done to a child, elder, or a person with a disabilityWhen compelled to disclose information by a court orderAdditional Information:You acknowledge that the facilitating therapist of group therapy sessions and MUHSEN are not medical doctors or your personal therapists. Any advice or recommendations given during group therapy sessions are not intended to be medical advice, diagnosis, or treatment. Participants agree not to hold Muhsen or support group facilitators liable for any decisions they make.Contact with the therapist and facilitator will remain within the group therapy sessions only. Information provided by the facilitating therapist and Muhsen representatives is intended to educate and empower participants, not replace professional medical guidance. You should always consult with a qualified medical professional before making health decisions.By signing this consent form, I confirm that I have carefully read and understand this Informed Consent Form, and that I agree to its terms and conditions. I acknowledge that the co-facilitators have provided the opportunity to discuss and ask questions about the importance and limits of confidentiality, as well as the expectations of the group.
*
Yes, I agree
Do you need respite?
No
Yes
Gender of participant
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Female
Male
Name of Participant
*
First Name
Last Name
Disability of Participant:
*
Age of Participant
*
Do they have some kind of supportive device? If so, what is it?
*
What is their best mode of communication?
*
What do they find challenging?
*
What are the challenging behaviors we are likely to see when they are upset?
*
How should one calm a negative behavior?
*
List any dietary restrictions for them? Do they have any allergies? Any food sensitivities/texture sensitivities
*
List any applicable information for toileting
*
What are their preferred activities?
*
What are some strengths of theirs that we can build on?
*
Is there any additional information you would like to share?
*
Suggested Donation of $5
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