Mailing Address: PO Box 774, Agoura Hills, CA 91376 Email: email@example.com 818-788-HOPE
1. Length of Series: The series are time specific and each series runs for 8 weeks. At the 6th week, the therapist will begin to check with the group to see if there are enough people interested in committing to another 8 week series.
2. Fees: There is a one time orientation fee of $50 and the weekly fee for each session is $30. The total amount for the series is $290 ($240 for 8 groups plus $50 for orientation). That amount is to be paid in advance at the beginning of the 1st meeting. Individuals added later in the series will be responsible for the group meetings that they will be attending. Special arrangements may be made with the therapist if there is a financial hardship.
3. Patient absences: There is no fee adjustment 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. Refunds: Once you are commited to the 8 week series there will be no refunds.
5. Commitment: You have committed to attend weekly for 2 months, 8 sessions. At any time into the series, if 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.
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 therapists is allowed 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.
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.
Payment for Sessions
I agree to pay for the 8 groups and orientation at the beginning of the series. Remember, the group meets and expenses are incurred whether you attend or not. There are no refunds for missed or for leaving the group.
Please send your completed paperwork and your check for the series to:HOPE Connection, PO Box 774, Agoura Hills, CA 91376
I have read the above information on videoconferencing psychotherapy, the limitations, and confidentiality caveats. With this understanding, I wish to participate in videoconferencing psychotherapy sessions when health or other concerns prohibit our being able to meet in person.