Group Therapy Privacy Form

Willow Creek is required by law to protect your private health information and adheres to the guidelines of confidentiality established by professional organizations and state law. As a member of this group, you also have the right to respect and privacy. Confidentiality within the group setting is a shared responsibility of all members. While group leaders cannot disclose information except as provided by law, group member’s communications are not protected, and there is a risk of disclosure of confidential information to third parties. As such, confidentiality within the group setting is dependent on the members’ commitments to honor one another.

I understand and agree to the following:
That I have been informed of the risks of group therapy*
Yes
Not to disclose to anyone outside the group any information that may help to identify another group member, including but not limited to: names, physical descriptions, biological information, and specifics to the content of interactions with other group members*
Yes
To hold the undersigned therapist harmless from any claims or liability resulting from disclosure of confidential information by myself or a co-participant to a third party outside of the group*
Yes
That any form of physical contact is not permitted within the group setting*
Yes
To attend on time and stay for the entirety of the meeting*
Yes
That cellphone use is not allowed during the duration of the meeting*
Yes
To let the group leader and members know if I will miss a meeting beforehand in a timely fashion*
Yes
That as long as I am a group member I will not subgroup with other group members outside of group time(hangout, date, etc.)*
Yes
That I may choose to discontinue group therapy at any time*
Yes
Name*
First Last
Email*
Client Signature*
Date*
MM slash DD slash YYYY
Therapist Signature
Date
MM slash DD slash YYYY

Group Therapy Privacy Form

Group Therapy Privacy Form

I understand and agree to the following:

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