Group Therapy Informed Consent

Date

First Name *

Last Name *

Email Address *

My therapy group is: *Armed Forces VeteransLaw EnforcementTrauma Recovery

Please read and check each box here below. The form will not go through unless all boxes are checked.

Group therapy is a unique relationship in which a group of people who are likely experiencing similar difficulties come together to receive help. Dr. Z attempts to create an environment where honest, interpersonal exploration will occur that will benefit all participants. To create this environment, there are certain guidelines that need to be agreed upon by each participant.

CONFIDENTIALITY & NON DISCLOSURE. Group therapy is effective because individuals feel safe to share private information in a confidential atmosphere. It is important that every member of the group agree to uphold the confidentiality of the therapeutic setting. Members agree to keep names and identities of other group members confidential. If a member of the group has his or her own individual therapist and there is need for consultation, it is important to note that only the individual who made the request will be identified; all other group members’ information will be de-identified and kept confidential.

ATTENDANCE. Group therapy is successful (as is any form of therapy) when there is regular attendance by participants. If you cannot attend a group meeting, please email or call to let Dr. Z know as soon as possible. In your message please also indicate whether or not it is permissible for Dr. Z to share with the group why you are absent. Please arrive on time. If you miss and do not call ahead of time, you will be charged for the session.

ACTIVE PARTICIPATION. Members of effective groups actively share thoughts, reactions, and feelings during group meetings as a way of increasing their self-understanding and contributing to the personal growth of other members. To support that goal, Dr. Z will strive to establish and maintain a climate of respect within the group. Each member will undoubtedly share in different ways and be comfortable with different levels of disclosure. It is requested that as a participant you share what is comfortable and actively listen and attend to other group members. Participation does not necessarily mean talking. It can also mean listening to what other members have to say. No one will ever be forced to share anything that they are not comfortable sharing.

RELATIONSHIPS. Members agree to primarily use relationships in the group therapeutically, not socially. The group provides an opportunity for learning about oneself in relation to others. If, by chance, members meet outside the group, then it is their responsibility to discuss any relevant aspects of that encounter at the next group session. Group members are asked to refrain from dating or engaging in close friendships other members of the group while the group is ongoing.

WITHDRAWAL. Starting a new group can be difficult and even awkward at first, and Dr. Z requests that you please attend a minimum of three sessions before deciding to quit group therapy. Members will let the group know in advance if they are leaving the group. Group participation is on a voluntary basis. If you or Dr. Z determine that group therapy is not serving your needs, you will be referred to other options.

INFORMED CONSENT. Signing below means that you have read, give your consent to, and agree with the guidelines and will do all in your power to uphold them. Should it be discovered that you are in breach of any of the policies above, Dr. Z may ask that you terminate your participation in group therapy and refer you to other options.

I (Client) have read, understood, and agreed to the terms and conditions stated above.

Your signature *Please type your full legal name. This will be your legally binding electronic signature.

Informed Consent for Group Therapy

Dr. Mark R. Zuccolo, PhD, LMFT

Bellagio Psychotherapeutics