Family Caregiver Support Group Sign Up and Informed Consent

Family Caregiver Support Group Sign Up and Informed Consent

In order to ensure that our support groups are the best fit for you, please read and reply to the questions below. One of our support group facilitators will contact you to follow up. Thank you!
Please note that support group participation is limited to a) residents of San Luis Obispo County, b) those who are at least 3 months sober if previously in a recovery program, and c) those who live in safe and stable housing.
Today's Date

MonthDayYear
Date
Your Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
E-mail
example@example.com
Street Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Gender
How did you hear about this support group?

Other
Name of the Person Receiving Your Care

First NameLast Name
Your Relationship to that Person
Illness Requiring Care
Prognosis
Is the person requiring care living in your home?
If no, where does the person live? (e.g. their own home, another family member's home, assisted living, nursing or memory care facility)
What is the distance between your home and theirs?
Have you been a caregiver in the past?
If yes, for how many years were you a caregiver and when did your caregiving relationship end?
Do you currently participate in the caregiving of any additional people?
If yes, please describe the additional caregiving roles
Do you feel that you have an adequate support system?
If not, please explain
Are you in individual counseling?
If yes, where?
Other than counseling, is there anyone with whom you speak regarding the challenges of caregiving, including personal impact?
Have you ever been part of a support group before?
Please indicate the level of importance to you for getting factual information about caregiving
Please indicate the level of importance to you for having a safe place to express feelings and discuss the challenges related to illness
Please select the emotions and situations that are most concerning to you in your caregiving experience
Please feel free to share other concerns that have come up for you
Group participants are caring for people with a variety of serious illnesses. Some of the stories will be very familiar, but some participants may share illness details and challenges that are different from your own. Knowing that, how do you think it will be for you to listen to others share their stories about the people for whom they care as well as the possibility of grieving (including having started the grieving process), death and loss?
What are your hopes or fears in coming to the group?
Hospice SLO County provides grief counseling services on an individual, yet limited basis meaning we specialize in short-term grief education and counseling and therefore should not be mistaken for more traditional counseling which may address longer-term goals. I understand that if I am in crisis, I can call Central Coast Hotline at800-783-0607 (24 hours, 7 days a week) or dial 911 to get emergency help.
I understand that all information shared in group sessions is confidential, and it is an expectation that I will keep the confidences of other group members as well as the others keeping my confidences. I understand that group facilitators maintain professional boundaries to protect confidentiality.
I understand that group facilitators keep group sharing confidential with some limits. As mandated reporters under section 11161.5 of the California Penal Code, group facilitators must report the following: Any suspected child abuse reported to Child Protective Services and/or law enforcement within 36 hours. Suspected elder abuse (anyone over the age of 65 years), or the abuse of dependent adults reported to Adult Protective Services. Any stated intent to do physical harm to another person or to destroy the property of another person, we must notify the police and the intended victim. Any stated intent to self-harm, group facilitators must make every effort to ensure my safety which may include hospitalization.
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