Information & Registration Form
GROUP THERAPY CONSENT FORM
Fees and Appointments
Group sessions ordinarily take place once per week, unless otherwise arranged. If you are unable to attend a group session, please contact your group leader to inform them of your absence as soon as possible.
A brief individual intake session is required for group participation. This will take place via a virtual visit. Groups can be covered under insurance. If not electing to use insurance, the fee is $25 per group session. Payment is due prior to the start of group sessions.
Groups are significantly affected when group members are absent. Therefore, attendance is strongly encouraged. Even though you may be absent from time to time, your place in the group is reserved and you are responsible to pay for any missed sessions without prior notice of at least 24 hours.
Confidentiality
Communication between you and the group leaders is both privileged and confidential. This means that group leaders cannot discuss your case orally or in writing, except with the My Tribe, LLC staff.
Confidentiality is strongly encouraged among group members.
Your group leaders have an ethical and legal obligation to break confidentiality under the following circumstances: if there is a reason to believe there is an occurrence of child, elder or dependent adult abuse or neglect. If there is reason to believe that you have serious intent to harm yourself, someone else, or property by a violent act you may commit. If there is a court order for release of your records.
Contacting Me and After Hours Emergencies
Because this is a limited private practice, I am often not immediately available by telephone. When I am unavailable, please leave a message on our voicemail. I will make every effort to return your call within 24 hours, with the exception of weekends and holidays. If I will be unavailable for an extended time, such as for scheduled vacation, I will provide you with the name of a colleague to contact if necessary. In the event of a psychiatric emergency, and you are unable to reach me, please call a local Mental Health Hotline, DIAL 911, or go to the nearest Emergency Room of your nearest hospital and ask to be evaluated by the psychologist or psychiatrist on call. For less urgent matters or for scheduling issues, please leave a message on my voicemail or send an email. Email is not a secure, confidential form of communication and should not be used for discussion of clinical issues or for urgent communications.
Informed Consent to Treatment
I have read, understood, and have had opportunity to question, and I agree to the above conditions and policies. I agree and consent to participate in behavioral heath care services offered and provided at My Tribe LLC.
If the patient is under the age of 18 or unable to consent to treatment, I attest that I have legal custody of this individual and am authorized to initiate and consent for treatment and/or legally authorized to initiate and consent to treatment on behalf of this individual.
I also permit the use of a copy of this signed authorization in place of the original.
Insurance & Benefit Information (if applicable) Insurance Company