Your Authentic Self “YAS” Support Group

Full Name of Group Member*

Age of Group Member*

Full Name of Parent/Guardian*

Emergency Contact Full Name:*

Emergency Contact Relationship:*

Emergency Contact Phone Number*

Please enter a valid phone number.

This signed consent form demonstrates your agreement to participate in the YAS Support Group. We are an open support group. We ask that members of the group maintain the confidentiality of other members, however, recognize that we can not guarantee this and it is contingent upon each members respect and understanding of one another’s need for safety and privacy.

LIMITS

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 to be psychiatrically screened.

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. 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

Respect other members of the group
Respect yourself
Respect the process: Arrive on time and stay the full time. Make a commitment to attend each week.
Maintain confidentiality of one another.

The signatures here show that we each have read, discussed, understand, and agree to abide by the points presented above. and that we agree to attend the group. After reading this form, I understand that I am free to discuss any concerns or questions with a group leader. The purpose of the group is to provide support.

Youth Name

Signature of Parent/Guardian

Signature of Group Member

The mission of Ocean Partnership for Children (OPC) is to enhance the well-being of youth and their families through natural and community supports.