Group Informed Consent And Patient Responsibilities Form

GROUP INFORMED CONSENT AND PATIENT RESPONSIBILITIES
The benefits from group therapy can be many. Enhancement of basic social skills (reading facial expressions/body
language, engaging peers, impulse control, decision making skills, etc.), increased awareness of how one’s behaviors
impact relationships, better coping skills (anger management, time management, frustration tolerance, etc.) and a sense of
validation amongst peers are all possible outcomes. Group psychotherapy may involve the risk of remembering
unpleasant events and arouse intense emotions of anxiety, sadness, anger and depression. In addition, while there is a
general consensus in outcome research that most people are helped when they are matched with the right therapist, there is
no guarantee that this therapy will lead to the desired results.
Within certain limits, information revealed by participants in group therapy will be kept strictly confidential by the
therapist and will not be revealed to any person outside of the group or to any outside agency without your written
permission. An inherent risk with group psychotherapy is the confidentiality of information disclosed, as all group
members verbally agree to hold information disclosed as confidential but law and ethics do not bind this agreement. If
you want insurance invoices, insurance carriers typically require that the dates of treatment, fees and diagnosis be
disclosed. There are certain situations in which, as a psychologist, I am required by law to reveal information
obtained during any form of therapy to other persons or agencies. These situations are as follows: 1) if you are a
threat of grave bodily harm or death to self or another person, 2) if I become aware of a situation of neglect or harm of a
minor or an elderly individual, 3) if a court of law issues a legitimate subpoena, and/or 4) you are a court-referred client.
If I believe there is risk of you harming someone else or self-inflicting harm, I am not mandated, but have an ethical
responsibility to give this information to appropriate persons in order to obtain the best care for you and those you may
harm. Additionally, information may be shared with others therapists associated with this corporation and/or with
supervisors, all of whom are bound by the same confidentiality laws. Although the parent of a minor is the “holder of
privilege,” disclosing the content of sessions with minors to parents tends to undermine therapy. Reporting to parents is
kept to general progress/issues or if the minor is involved in dangerous or harmful activities.
Group therapy expenses are your responsibility regardless of insurance coverage. Due to the nature of group therapy,
group fees are to be paid in full prior to the commencement of group sessions unless otherwise specified. Checks
are to be made out to “Fulton and Associates.” Payment ensures reserved placement in an age appropriate group as well
as consistency among group members throughout the duration of the group cycle to enhance the group therapy process/
experience. Monthly invoices will be provided upon request so that you may attempt to receive reimbursement from your
insurance company. Prorating is not available due to limited group space and the need to assure reserved placement for
each group member at each group session. No Shows and Late Cancellations will be charged the full weekly group fee
($55). In the event of non-payment a collection agency or small claims court may be utilized, and you will be responsible
for reasonable collection fees. Group therapy fees are $550 per 10-week cycle, unless otherwise specified. Group therapy
meetings range from 45 minutes to 1 hour, depending on participants’ age. Should cancellation of group be required due
to a therapist absence or a therapeutic emergency, all efforts will be made to notify group members in advance or another
therapist from the practice will cover the group.
A licensed psychologist or a psychological assistant may conduct groups. A licensed psychologist will provide
supervision to all psychological assistants. If there are any concerns or questions regarding psychological assistants
please contact Dr. Christopher Fulton at (818) 591 3000. In the case of an emergency the following numbers are
beneficial. If a family member is threatening violence or suicide, you need to call 911. The police are well trained in
handling situations ranging from suicidal individuals to out-of-control teenagers. Additional numbers you may find
beneficial include: California Youth Crisis Line (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 signing this Group Informed Consent and Patient Responsibilities form I am acknowledging that I have read and
understand the above explanations regarding informed consent, confidentiality, and patient responsibilities. I agree to
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
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