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Support Group Registration

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Support Groups
I'm registering for the following group(s):

Please read and consent to the terms of the Support Group

I hereby consent to engaging in grief related group support via Microsoft Teams.

I understand that group support may include the practice of grief support and education using interactive audio, video, or data communications.

I understand the following with respect to Tabitha Support Group:

  • I understand that there are risks and consequences from distance support groups, including, but not limited to, the possibility, that despite reasonable efforts on the part of the group facilitator, that: the transmission of confidential information could be disrupted or distorted by technical failures. These risks are offset by the use of Teams, a HIPAA-compliant service which is encrypted for video health communications. Further, the contents of my group facilitator’s computer are encrypted.
  • In addition, I understand that virtual support may not yield the same results nor be as effective as face to-face service. 
  • In emergencies, in the event of disruption of service, or for routine or administrative reasons, it may be necessary to communicate by other means, including telephone or secure email. I understand that non-encrypted email is not secure and should not be used to convey HIPAA protected information.
  • It is my responsibility to maintain privacy on the group member end of communication. This includes NOT recording support group sessions. It also includes not using the chat/typing feature during sessions.
  • I understand that there are potential limits and benefits associated with any form of support group despite good intentions. I understand that the support group facilitator may suggest the further support of a licensed professional and that I could ask for a referral if the support group does not seem adequate for my needs.
  • I acknowledge, however, that if I am facing or if I think I may be facing an emergency situation that could result in harm to me or to another person; I agree to seek care immediately through my own local health care counselor or at the nearest hospital emergency department or by calling 911.
Consent

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