We will treat what is told to us with great care. Our professional code of ethics (that is, our profession’s rules about values and moral matters as described by American Psychiatric Association) and the laws of this state prevent us from telling anyone else what group members tell us unless they give us written permission. These rules and laws are the ways our society recognizes and supports the privacy of what we talk about—in other words, the “confidentiality” of therapy including group support. However, we cannot promise that
everything group members tell us will never be revealed to someone else. There are some times when the law requires us to tell things to others. There are also some other limits on our confidentiality. We need to discuss these, because we want you to understand clearly what we can and cannot keep confidential. Our group members need to know about these rules now, so that they don’t tell us something as a “secret” that we cannot keep secret. So please read these pages carefully and keep a copy. At the first group meeting, we can
discuss any questions you might have.

When you or other persons are in physical danger, the law requires us to tell others about it.

Specifically:

a. If we come to believe that you are threatening serious harm to another person, we are required to try to protect that person. We may have to tell the person and the police, or perhaps refer you for psychiatric screening.

b. If you seriously threaten or act in a way that is very likely to harm yourself, we may refer you for psychiatric screening, or to call on your family members or others who can help protect you. If such a situation does come up, we will fully discuss the situation with you before we do anything, unless there is a very strong reason not to.

c. In an emergency where your life or health is in danger, and we cannot get your consent, we may give another professional some information to protect your life. We will try to get your permission first, and we will discuss this with you as soon as possible afterwards.

d. If we believe or suspect that you (or another minor or elderly person) are being abused. We must report this to the NJ Abuse to further investigate.

Other Limits to Confidentiality:

A safe environment is created and maintained by the group facilitator and its members. Although we are bound by confidentiality as stated above as group members you are bound by honor to maintain the confidentiality of your peers. We ask that you do not discuss the group, its members or what is said in the
group with others. We realize you may want to talk about the work you are doing or other significant ways the group has impacted your life. This is fine, but please remember to not compromise the confidentiality of other group members in the process.

GENERAL GROUP RULES

1. Respect other members of the group
2. Respect yourself
3. Respect the process: Arrive on time and stay the full time. Make a commitment to attend each week.
4. Confidentiality: this is very important! The group environment needs to feel safe for everyone. It is vital that you keep what is said in the group confidential. Do not discuss other members with anyone outside of the group (this includes other group members). Facilitators cannot enforce confidentiality although we strongly encourage it.

The purpose of the group is to provide education and support. I understand these groups are not treatment related; rather provide psychoeducation. I understand that my child may receive information, education and support. I understand the nature of this group is an open group and approved new members can join for any length of time. I agree to contact Victoria Azzopardi, LCSW at 732-202-1585 x117 if I have any questions, concerns, or disagreement with the group’s focus or material.

I hereby consent to my child's participation in video conferencing with the indicated Ocean Partnership for Children Group. I understand the following with respect to video conferencing:

1. I understand that I have the right to withdraw consent at any time without affecting my right or my child’s right to future care, services, or program benefits to which I would otherwise be entitled.

2. I understand that there are risk and consequences associated with video conferencing, including but not limited to, disruption of transmission by technology failures, interruption and/or breaches of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies.

3.I understand that there will be no recording of any of the online sessions by either party. All information disclosed within sessions are confidential and may not be disclosed to anyone without written authorization,except where the disclosure is permitted and/or required by law.

4.I understand that the privacy laws that protect the confidentiality of my child’s protected health information(PHI) also apply to video conferencing unless an exception to confidentiality applies (i.e. mandatory reporting of child, elder, or vulnerable adult abuse; danger to self or others).

The signatures here show that the parent/guardian of the youth attending the group has read, discussed, understand, and agree to abide by the points presented above.