Fillable Printable Information and Consent for Group Participation Form

Information and Consent for Group Participation Form

Information and Consent for Group Participation

Entering a therapeutic group can be a highly rewarding and powerful experience. There are some

obvious limitations to group work that will be outlined. Group work can also enhance individual

therapy work but it is not intended to replace individual treatment for various mental health symptoms

or disorders.

The expectation is that group participants commit to 6 months of group participation. You have the

right to discontinue the group at any time for any reason. However, it is requested that you discuss

with the group leader any issues or concerns you may have regarding the group, facilitator, group

process or its members. It is requested that you notify the facilitator if you have a prior commitment or

are unable to attend group. You are allowed two miss two groups without charge in a 6-month period.

After two missed groups, participants are responsible for paying the full fee for the missed group.

Confidentiality including names and identifying information of all group members is to be respected

throughout the course of the group and afterwards as well as it relates to information shared during

group. It is also requested that group members refrain from any intimate outside relationships with one

another during the course of the group series.

It is your responsibility to pay designated fess for group services at the time of group or as mutually

agreed upon. This fee is agreed to be $50 per 90-minute group session. Session fees can be made with

cash, credit/debit card, PayPal or check. No insurance will be filed on groups.

There are many benefits to therapeutic groups including learning new tools and skills, increased self-

awareness, better relationships with others, and improved quality of life. It may be that there are

periods of emotional release and/or establishing new habits and patterns that require extra self-care

and/or altering your current lifestyle in order to best manage the presenting issues and possible

accompanying symptoms. It is also important that you communicate with your individual counselor if

additional work is needed on an issue that arose during group. It is considered the group participant’s

responsibility to seek additional individual sessions in the event that it is needed.

Regarding your right to client confidentiality, you need to be aware that there are a few exceptions to

your right to complete confidentiality. These circumstances include the event that your safety or the

safety of another person is in question. Counselors are also required to break confidentiality in cases of

abuse, court-ordered testimony, or subpoena of client records.

I have read and understood this consent form and agree to voluntarily participate in group therapy

facilitated by Jenna Longmire, M.A., Licensed Professional Counselor. I have received a copy of this

document if requested.

_________________________________________ ___________

Client or guardian’s signature Date

_________________________________________ ___________

Jenna Longmire, MA, LPC Date