NOTE: If the client is 18 years of age or older, the client is the only person permitted to complete and sign this form. If the client is under the age of 18, the parent or legal guardian must complete and sign this form.

Acknowledgment of receipt and understanding: 

I acknowledge that Serenity-BHS has provided me with a copy of the Client Welcome Packet which informs me of Serenity-BHS' Cost of Services policy, Client Rights policy, and HIPAA policy.  I have read and understand the information presented in the Client Welcome Packet and acknowledge that I have the ability to make decisions in regard to my own healthcare needs.

Note: the Client Welcome Packet can also be found on our website, www.serenity-bhs.org.

Communication Policy:

I consent to communications between myself and the group lead therapist through the use of phone calls, emails, and/or cell phone texting in order to receive updates related to my group or to relay cancellations. I understand that I should only communicate non-confidential information via email and texting with the group lead therapist.

Cost of Services Policy: 

Serenity-BHS aims to provide effective group counseling services to you and your family. The insurance you have on file with us will be billed for your group therapy session. If your insurance does not allow for group therapy billing, the session fees will be your sole responsibility at $40 per session.

• I understand that my insurance will be billed
• I agree to pay the fees associated with my group therapy participation if my insurance does not cover group therapy sessions

Absenteeism and Late Notice Cancellation Policy:

If I intend or need to cancel my group-therapy session, I understand that I must give more than 24 hours notice to avoid paying a $40.00 late notice cancellation fee. I understand that I have a right to terminate my group participation at any time.

I understand that in the event I do not attend a scheduled group session and cancel with more than 24-hour's notice, I will not be charged a late notice cancellation fee. If I miss 3 scheduled group sessions, regardless of reason or whether I canceled with more than 24-hours' notice, I will be discharged from the group. 

Inclement Weather Policy:

I understand that in the event of inclement weather, or therapist(s)/facilitator(s) are unable to provide in-person sessions, the therapist(s)/facilitator(s) will have the group meet remotely and will send an invite to all group members to join the group via telehealth using Microsoft Teams.

I understand that the group will return to its in-person structure at the next possible scheduled session.

Informed Consent for Treatment:

I understand that participating in group sessions will involve talking about my personal thoughts, feelings, and experiences. I understand that group therapy may cause additional stress or emotional difficulty during the course of learning how to resolve and address my presenting problems. I understand that if a crisis occurs during group, as it relates to my mental health treatment, I can contact the National Crisis Hotline, 988 or call 911 for assistance. I also understand that the group leader (therapist) may ask to refer me to external medical services if they feel it is necessary to meet my therapeutic needs. Such referrals may include a medical or psychiatric assessment and will require my signature on a Release of Information form before my group therapist can make a referral or release my records.

I understand that the group therapist(s)/facilitator(s) have their own rules and requirements for completing group therapy.

I understand that as a group participant, I will respect and comply with the following rules:

• Maintain respect of boundaries, information, and agency for all group members and therapists/facilitators
• Actively participate in group discussion and activities
• Refrain from all substance use (including cigarettes, chew-tobacco, and vapes) throughout the duration of group
• If I arrive later than 15 minutes (i.e., 6:16pm) my group session will not count toward the number of required sessions needed to complete the group; though, I am welcome to stay and participate in the group.

I understand that if I do not cooperate with these rules or the rules provided by the group facilitator, Serenity-BHS has the right to discharge me as a group participant from group therapy.

Upon my completion of the group, I will receive a Certificate of Completion that I can use with my discretion. 

Consent to Co-Facilitation:

I understand that Serenity-BHS may bring in additional therapists to co-facilitate established groups. Co-facilitators offer additional insights that can deepen the therapeutic process and their presence can bring additional expertise, perspectives, and therapeutic modalities to the group dynamic making group therapy an even more powerful tool for healing and self-discovery.

Sick Policy (COVID/Flu/Virus): 
 
I understand that Serenity-BHS follows CDC guidelines when cleaning offices and common areas to decrease the risk of spreading a virus. I also understand that Serenity-BHS group therapists and staff monitor their own health to ensure that they do not provide group therapy sessions if they have any COVID/Flu/Virus symptoms or have been exposed to anyone who has COVID. 
 
I understand that carriers of COVID/Flu or other infectious viruses may not show symptoms but may still be highly contagious. I understand that if I have any of the following symptoms listed below, I should cancel my group session:

• Fever/feverish chills
• Severe headache
• Sore throat
• Dry cough
• Shortness of breath or difficulty breathing
• Loss of taste or smell
• Extreme fatigue
• Runny nose
• Muscle or body aches 

I agree that I will not procede with an in-person group session if I exhibit any COVID/Flu/Virus symptoms which could spread to others through close contact.

I agree to cancel my group session if someone from my household or someone I have had recent close physical contact with, has COVID/Flu/Virus symptoms or are in isolation or quarantine.

Confidentiality Policy:

I understand that all Serenity-BHS group therapists and staff are committed to maintaining confidentiality. However, confidentiality will not not maintained where Serenity-BHS is legally required to notify others in situations such as the following:

• Any threat to harm self or others, including murder, suicide, and assault
• Any reports of actual or suspected child abuse, endangerment, or neglect
• Any reports, actual or suspected, of abuse of the elderly or dependent adult
• Any reports of actual or suspected animal abuse
• A clinician (therapist) is court ordered to testify, or a subpoena requires the release of such records to an attorney or investigator
• A guardian or legal custodial parent requests information by signing a Release of Information (ROI) form and are legally allowed to do so

Further, I understand that “what is said in group stays in group” meaning any personal information or identifying information obtained from others in the confidential space of group therapy is not to be discussed with anyone outside of the group space and times.

• I understand there will be no use of social media during group time and information shared within the group shall not be shared on social media.
• I understand that cell phones and smart devices will be turned off or on silent-mode and put away during group space and time, with the exception of using them during breaks. Cell phones and smart devices may not record any portion of group space or time. 

HIPAA Policy:

Your group therapist and/or co-facilitator may discuss cases with professional colleagues, without use of names and only when necessary, and will abide by all HIPPA laws as outlined in our agency’s policies and as required by the Ohio State Licensing Board.

I agree to the Group Therapy Participant Registration and Consent policies and procedures as outlined above.

I give consent for Serenity-BHS to charge my insurance for the cost of my services.

I consent for Serenity-BHS to use the credit card I have on file to process my group therapy fee of $40 if my insurance does not cover group therapy sessions.

I also give consent to Serenity-BHS to send me a confidential Client Survey to get my feedback about the group(s) I participate in.