Mailing Address: PO Box 774, Agoura Hills, CA 91376 Email: firstname.lastname@example.org 818-788-HOPE
1. Length of Program: This is a 2 year program from the date that you enter the groups.
2. Fees: There is a one time orientation fee of $50 and the weekly fee for each session is $30. The initial financial commitment is $290 ($50 orientation and $30 each for 8 groups, $240). That amount is to be paid in advance at the beginning of the first meeting. After the 8 week commitment, you will be invoiced at the beginning of each month for the month throughout the 2 year program. Special arrangements may be made with the therapist if there is a financial hardship. No one is turned away for lack of funds.
3. Group member absences: There is no fee adjustment or refunds for absences. We ask that you commit to be present each week. If an emergency arises and you are not able to attend, please contact the therapist who is facilitating the group.
4. Commitment: You have committed initially to attend weekly for 2 months, 8 sessions and ultimately to the 2 year program. If after the initial commitment and at any time in the program, you feel like the group is not a good fit, please first discuss with the facilitator and give a 2 week notice so that the group members can process and say goodbye. The group has shared a lot with you and held a space for your grief. This is respectful and fair.
5. Refunds: Once you are commited to the 8 week initial commitment, there are no refunds. There are no refunds for absences during the 2 year program.
6. Confidentiality: Maintaining confidentiality is important in order to create a safe place to heal. Every person in the group has a right to a confidential relationship with other members and has the ethical responsibility to protect them from any unauthorized disclosures of any information given in the group setting, including identities of group members. This helps to create a safe, warm, caring environment for every member who is attending our program.
7. Disclosure by the HOPE Connection is permitted and in some cases mandated by law to disclose under the following circumstances:
8. I agree to the terms and understand the principles involved in this grief support group as explained in these pages.
Videoconferencing Grief Support Groups Addendum to Informed Consent for Group
This form is to educate you about videoconferencing grief group sessions. When we cannot meet in person due to health or other concerns, videoconferencing is an option available to us.
Technology for Videoconferencing Sessions
Videoconferencing grief support groups are provided on a HIPAA-compliant Zoom platform. This platform allows for real-time video communication. You do not need your own Zoom account to join in the “Zoom room” but it is much easier if you download the app, Zoom Cloud. You will need a computer, smart phone or ipad with a video-camera and a microphone. (A computer allows more stability and the ability to see the entire group on your screen.) A day or so before the meeting, you will receive an email Zoom invitation. It will provide you with a link to click on and a Meeting ID. The ID number changes each week. At the time of the meeting, click on the link and a video screen will open. You may have to click on links on your screen to turn on your microphone and camera.
Limitations Due to Use of this Technology
A variety of technological problems can cause delays in starting meetings or can interrupt a meeting. If you cannot successfully connect or reconnect on video, you can call the number on the invitation and connect by telephone. They will ask for the Meeting ID to enter the discussion. They may also ask for a password.
The following are steps to increase security and confidentiality of the Zoom groups.
1. The Zoom videoconferencing platform and its Epic software are HIPAA-compliant. Our meetings are encrypted with AES-256 bit encryption and dynamic password protected.
2. I agree to not record the videoconference group meetings. 3. The group meeting will be locked down by the facilitator as soon as everyone arrives. No one new can join at that point.
4. I agree to limit interruptions and protect confidentiality by being alone in a quiet room and closing the door to the room. People may forget and walk in, other phone lines and doorbells ring, pets make their presence known, etc. I will do my best to limit these interruptions.
I have read the above information on videoconferencing groups, the limitations, and confidentiality caveats. With this understanding, I wish to participate in videoconferencing support groups when health or other concerns prohibit our being able to meet in person support groups.