Fillable Printable Group Informed Consent And Patient Responsibilities Form
Fillable Printable Group Informed Consent And Patient Responsibilities Form
Group Informed Consent And Patient Responsibilities Form
GROUP INFORMED CONSENTAND PATIENT RESPONSIBILITIES
The benefits fromgrouptherapy can be many.Enhancementof basic socialskills(reading facial expressions/body
language,engagingpeers,impulse control, decisionmakingskills, etc.),increased awareness ofhow one’s behaviors
impactrelationships, better copingskills (angermanagement,time management, frustration tolerance, etc.) and a sense of
validation amongstpeers are all possibleoutcomes. Grouppsychotherapymay involve the risk of remembering
unpleasantevents andarouseintenseemotions of anxiety,sadness,anger anddepression.In addition,whilethere is a
generalconsensusinoutcomeresearchthatmostpeople are helped when theyare matchedwith the righttherapist, there is
no guarantee that this therapy will lead to the desired results.
Withincertainlimits,informationrevealedby participants ingrouptherapywill bekeptstrictlyconfidentialbythe
therapistandwill notbe revealed to anypersonoutsideofthegrouportoanyoutsideagencywithoutyourwritten
permission. Aninherentriskwith grouppsychotherapyis the confidentialityofinformationdisclosed,asall group
membersverbally agreetoholdinformation disclosedasconfidentialbutlawandethicsdo notbindthisagreement.If
youwantinsuranceinvoices, insurance carriers typically require thatthedates of treatment,fees anddiagnosis be
disclosed.There arecertainsituationsinwhich,asapsychologist,I amrequired bylaw torevealinformation
obtained duringanyformoftherapy toother personsor agencies.These situations are as follows: 1)ifyou are a
threatof grave bodilyharm or death to self or another person, 2) if I become awareofa situation of neglectorharm ofa
minororan elderlyindividual, 3) if a courtof lawissues alegitimate subpoena, and/or4)youare a court-referredclient.
IfIbelieve there isriskofyouharming someoneelseor self-inflicting harm,Iam notmandated, buthave anethical
responsibility to givethis information to appropriate persons inorder to obtain the bestcareforyou andthose youmay
harm.Additionally, information maybesharedwithothers therapistsassociatedwith thiscorporation and/or with
supervisors, allofwhom are bound bythe same confidentiality laws. Although theparentofa minor is the“holder of
privilege,”disclosingthecontent of sessions with minorsto parentstends to undermine therapy.Reporting toparents is
kept to general progress/issues or if the minor is involved in dangerous or harmful activities.
Group therapy expensesare your responsibilityregardless ofinsurance coverage.Duetothenatureofgroup therapy,
group fees aretobe paidin fullprior to the commencement of group sessions unlessotherwisespecified. Checks
are to be made out to“Fultonand Associates.”Paymentensures reservedplacement in anage appropriate group as well
as consistency amonggroup membersthroughouttheduration ofthe group cycle to enhancethe grouptherapyprocess/
experience.Monthlyinvoiceswill be provided upon requestsothatyou may attempttoreceive reimbursementfrom your
insurance company. Proratingis notavailable due to limitedgroup space andthe needto assurereserved placementfor
each group member at eachgroupsession. No Shows andLate Cancellationswillbe chargedthe full weekly group fee
($55). In the eventof non-paymenta collection agency or small claimscourtmay be utilized, andyouwill be responsible
for reasonable collection fees. Group therapy feesare $550per 10-weekcycle,unlessotherwise specified.Grouptherapy
meetingsrange from 45minutes to 1 hour, dependingon participants’age. Shouldcancellationof group berequireddue
to a therapistabsence or a therapeuticemergency, alleffortswill be made tonotify groupmembersinadvance oranother
therapist from the practice will cover the group.
A licensedpsychologistor a psychological assistant mayconductgroups.A licensedpsychologistwillprovide
supervisionto allpsychological assistants. Ifthere are anyconcernsorquestions regarding psychological assistants
pleasecontactDr. ChristopherFultonat(818)591–3000.Inthe caseofanemergencythefollowingnumbers are
beneficial. Ifafamily memberisthreateningviolence orsuicide,youneed tocall 911. The policearewelltrainedin
handling situationsrangingfrom suicidal individuals toout-of-controlteenagers.Additionalnumbers you mayfind
beneficialinclude: California Youth CrisisLine (800) 843–5200, Child Abuse Hotline (800) 540–4000,Domestic Abuse
Hotline (323) 681–2626, Elder Abuse Hotline (800) 992–1660 and the Suicide Prevention Center (310) 391-1253.
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By signingthis GroupInformed ConsentandPatientResponsibilitiesformIamacknowledging thatI have readand
understandthe aboveexplanations regarding informed consent,confidentiality, and patientresponsibilities.Iagreeto
enter/have my child enter a group psychotherapy relationship under the terms outlined in this form.
Patient/ Group Participants Name: ____________________________________________ Date: ______________
Parent Signature (if group participant is a minor): ________________________________
Updated 03/2007
