Group Therapy Consent

* indicates a required field

* I consent to sharing information provided here.
I understand that the purpose of group therapy is to gain and share
wisdom from peers in a therapy setting under the guidance of therapist

* I consent to sharing information provided here.
I understand that confidentiality is important in group settings –
discussing the experience of other members outside of session can be
harmful and considered gossiping; breaking confidentiality may result in
being asked to leave the group without refund

* I consent to sharing information provided here.
I understand that dating and making personal friendships within the
group is typically counterproductive to the therapy process – this makes it
harder for the individuals to open up or call each other out due to the
personal relationship that has been formed; making friends after the group
has ended is encouraged but not required

* I consent to sharing information provided here.
I understand in the group setting, I might be listening more than I
might be speaking – don’t stress, this is normal and even just listening
provides a lot of new insight for the individual. Remember the acronym
“T.H.I.N.K. – True, Helpful, Inspiring, Necessary, Kind”

* I consent to sharing information provided here.
I understand that showing up to all sessions possible, showing up on
time, respectful communication, giving attention, and showing up sober are
all important aspects of being respectful to the larger group, including the
therapist

* I consent to sharing information provided here.
I will do my best to suspend judgment of other people’s lifestyles within
the group, including sexuality, race, religion, economic status, nationality,
relationship status, etc. – remember, life is big and varied. What the right
answer and lifestyle is for you might not be true for someone else, but we
still might learn from it

* I consent to sharing information provided here.
I understand that it is the duty of both the therapist and group to pause
and address issues related to respecting others in group

Consents to Start Treatment

* indicates a required field

Informed Consent

Due to the nature of treatment, it is important for the client to be well informed of
typical practices within the Solid Ground Counseling and Therapy Services. Any further
questions can be discussed with your therapist. For the purposes of this document, “I”
would indicate the client.

* I consent to sharing information provided here.
I understand that therapy is a commitment to treatment and that
sometimes treatment can result in uncomfortable feelings, which are
something to work through in treatment.

* I consent to sharing information provided here.
I understand that therapy cannot ‘guarantee’ any results or behavioral
changes, but therapist will make best efforts to assist with positive change.

* I consent to sharing information provided here.
I understand that neither Solid Ground Counseling and Therapy
Services nor my therapist is responsible for my behavior inside or outside
of session.

* I consent to sharing information provided here.
I understand that the role of the therapist is to assist me to learn about
myself, help me reflect on behaviors, help me understand/reflect on
relationships, and make best efforts to reach my behavioral/emotional
goals.

* I consent to sharing information provided here.
I understand that it is my role as a client to be honest with my therapist,
to practice skills outside of session, to continually reevaluate life choices,
and to make best efforts to improve the self and relationships with those
around me.

* I consent to sharing information provided here.
I understand that I cannot have a sexual, romantic, or casual
relationship to my therapist. The relationship between therapist and client
is strictly professional.

* I consent to sharing information provided here.
I understand that any inappropriate behavior towards my therapist or
other employees within Solid Ground Counseling Services may result in
termination of treatment and referral to another therapy source.

* I consent to sharing information provided here.
(Individual sessions) I understand that I must pay the full session fee for
any scheduled appointments that were not cancelled or rescheduled within
24-hours. Any clients who habitually no show to session may be terminated
by therapist, as unstable sessions may not be effective for therapy.

* I consent to sharing information provided here.
I understand that the length of treatment cannot be guaranteed and
the length of treatment will be discussed between myself and my therapist,
however, six months to two years is typical for this type of treatment.

* I consent to sharing information provided here.
I understand that a debit or credit card will be kept on file for billing
purposes.

* I consent to sharing information provided here.
I understand that I can request or give permission to my therapist to
consult with others regarding my case via written or verbal request (written
strongly preferred).

* I consent to sharing information provided here.
I understand that I have a right to request to review my notes with my
therapist to ensure accuracy.

* I consent to sharing information provided here.
I understand that I have a right to request a copy of my notes and that
the request may be granted or denied as per the clinical judgement of
therapist and one other clinical therapist. Denials are based on potential
damage to the client or therapeutic relationship.

* I consent to sharing information provided here.
I understand that to enroll in treatment, I must be present in the state
of California or Texas for treatment. I will advise my therapist ahead of time
if I am going to leave the state.

* I consent to sharing information provided here.
I agree that all legal proceedings against Solid Ground and Counseling
Services will be conducted through binding mediation.

* I consent to sharing information provided here.
I understand that therapist will make best efforts to inform the client
aware of any attempted legal requests made on their record.

* I consent to sharing information provided here.
I understand that I will be billed my typical session rate per hour to
collaborate with my lawyer in criminal or civil cases.

* I consent to sharing information provided here.
I understand that if my therapist is called to testify, the therapist is
willing to appear at the rate of $5,000 a day per court.

* I consent to sharing information provided here.
I understand that any formal requested letters from therapist will be
billed for one typical session hour.

* I consent to sharing information provided here.
I understand that therapy ‘session hours’ are typically approx 53
minutes, but may be shorter or longer depending on situation.

Reporting Requirements

Due to the nature of treatment, it is important that the
client is well aware of the therapist’s reporting
requirements. If the following information is reported
to the therapist – a mandated report will be made with
no exceptions due to California and Federal laws.
Further inquiries can be made with your therapist.

* I consent to sharing information provided here.
I understand that if I express suicidal content or behavior of concern,
therapist may involve my emergency contact, known others, law
enforcement, or hospital staff for safety purposes only – the details of the
therapy case will not be provided to them unless it relates to immediate
safety concerns.

* I consent to sharing information provided here.
I understand that if I have any questions about the legality of seeking
treatment, I can consult with a lawyer and request a free anonymous
consultation with a therapist here at Solid Ground and Counseling Services.

* I consent to sharing information provided here.
Any child abuse (physical, sexual, emotional, neglect) that has been
conducted by either the client or any other party and the child is still under
the age of 18 years old.

* I consent to sharing information provided here.
Any elder abuse (physical, sexual, emotional, neglect, financial, social,
etc.) conducted by either the client or any other party.

* I consent to sharing information provided here.
Any use of child pornography.

* My emergency contact (name, phone number, address, can this
person drive, are they physically close to your home address)

* Is it ok to leave voice messages?

* I consent to sharing information provided here.
Any suicidal intent. Thoughts and feelings are something we work on in
therapy, any intention to harm self would require others to become
involved for safety purposes.

* I consent to sharing information provided here.
Any intent by the client to harm others.

* I consent to sharing information provided here.
Any mandates by a judge that requests records.

* I consent to sharing information provided here.
I understand that, though information may not be reportable, may still
be legally pursued if it is within the statute of limitations. (Can consult
lawyer if you have any questions related to statute of limitations).

* I consent to sharing information provided here.
All other information is kept confidential by therapist and not legal to
disclose without strictly de-identifying the information before hand.

Yes
No

* Is it OK to leave text messages? Ex. “Reminding you of an
appointment with Scott @____”

Yes
No