Maintenance Class Registration

This is a psycho-educational experience which means that you will be experiencing interplay between education, and personal processing and growth. Participation in this experience can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek attendance at a psycho-educational process. During the psycho-educational process, you may also encounter unpleasant feelings or thoughts. You may also make decisions about changes you would like to make in your behaviors and/or relationships. This experience may result in changes that were not originally intended. During the course of a psycho-educational process, your facilitators will draw on evidence-based research by Drs. John and Julie Gottman from the Gottman Institute. Attending a psycho-education process is not a substitute or alternative for individual psychotherapy or inpatient psychotherapy. If you are in need of names of counselors before, during, or after the psycho-educational process, your facilitators will be happy to provide you with a list of providers.

Please read the form below and sign. Your signature indicates that you understand and agree with the content of this form. Even if you are registered as a couple, each person will need to complete this form separately.

FINANCIAL

1. I understand that I am responsible for the cost of this group. All fees have been paid at the time of registration. If I am using my insurance, then I understand that any balance unpaid by my insurance will be my responsibility.
2. If I am using insurance, I have discussed payment with the Family Strategies billing department and understand my particular insurance coverage for this group. This includes deductibles, co-insurance, and copays.
3. Ultimately, I am responsible for the payment of services. If a third party is helping me financially, and they fail to pay, I will be given an invoice to deliver to the third party and discuss arrangements with them. If the third-party declines to pay, I will be responsible for my own fees.

I have read and agreed to the above conditions and have received a copy of the items in this commitment.

1. I realize that my therapy will take place in a group setting. I am encouraged to share on a personal level but will never be forced to do so. I can choose to share according to my own comfort level.
2. I recognize that there will be tools given to us to use and continue to implement in our daily lives.  The program only works if I do the work.
3. I commit to total confidentiality within the group. I will not disclose outside of group personal identifying information or stories about other group members. This includes sharing with my partner, family members, or friends. If sending email or texts, I will use extra precaution to seek permission with the recipient of the message before sending correspondence using either method. I will also not talk about other group members with a fellow group member. If I am concerned about the safety of a fellow group member, I will contact the facilitating therapist immediately. Failure to abide by confidentiality rules will cause me to be removed from participation in the group.
4. I understand that if I disclose the abuse of children, the elderly, or disabled, or report suicidal or homicidal feelings and/or intentions, the group therapist will be required by law to report such information to legal authorities.
5. I will challenge myself to open up and share on a personal level. I realize that the group will be more helpful to me if I learn authenticity. I will be honest with my feelings.
6. I realize that group therapy will never provide the necessary social interaction that will be found outside of the group. I will reach out to other participants outside of the group to get the support I need.
7. I will not bring children to the group.
8. I will not bring any type of firearm or weapon to the group.
9. I agree to have no sexual contact with other group members, nor to engage in solicitous behavior. Failure to abide by this agreement will cause me to be removed from participation in the group.
10. I will take responsibility for my own work. I understand that healing is an individual process that requires honesty and consistency.
11. I realize that group participation is not intended to meet all of my individual psychological and emotional needs. I will seek out individual therapy when needed. I understand that Family Strategies Counseling Center encourages participants to have a primary therapist to assist if the need for additional help may arise.
12. I understand that Family Strategies Counseling Center encourages participants to seek spiritual support from ecclesiastical leaders. The group does not impose spiritual or religious agendas.
13. Family Strategies utilizes E-therapy (teletherapy) services which are HIPAA compliant for security and confidentiality. However, I realize that there are limitations and risks associated with E-therapy, including inherent confidentiality risks of electronic communication and potential for technology failure. If there is an emergency and the therapist is unavailable, I should call 9-1-1.
14. Family Strategies does not allow either the counselor or client to record any portion of video or telephonic therapy sessions unless prior consent has been obtained in writing for the purpose of training or supervision.

This is a psycho-educational experience which means that you will be experiencing interplay between education, and personal processing and growth. Participation in this experience can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek attendance at a psycho-educational process. During the psycho-educational process, you may also encounter unpleasant feelings or thoughts. You may also make decisions about changes you would like to make in your behaviors and/or relationships. This experience may result in changes that were not originally intended. During the course of a psycho-educational process, your facilitators will draw on evidence-based research by Drs. John and Julie Gottman from the Gottman Institute. Attending a psycho-education process is not a substitute or alternative for individual psychotherapy or inpatient psychotherapy. If you are in need of names of counselors before, during, or after the psycho-educational process, your facilitators will be happy to provide you with a list of providers.

Please read the form below and sign. Your signature indicates that you understand and agree with the content of this form. Even if you are registered as a couple, each person will need to complete this form separately.

FINANCIAL

1. I understand that I am responsible for the cost of this group. All fees have been paid at the time of registration. If I am using my insurance, then I understand that any balance unpaid by my insurance will be my responsibility.
2. If I am using insurance, I have discussed payment with the Family Strategies billing department and understand my particular insurance coverage for this group. This includes deductibles, co-insurance, and copays.
3. Ultimately, I am responsible for the payment of services. If a third party is helping me financially, and they fail to pay, I will be given an invoice to deliver to the third party and discuss arrangements with them. If the third-party declines to pay, I will be responsible for my own fees.

I have read and agreed to the above conditions and have received a copy of the items in this commitment.

1. I realize that my therapy will take place in a group setting. I am encouraged to share on a personal level but will never be forced to do so. I can choose to share according to my own comfort level.
2. I recognize that there will be tools given to us to use and continue to implement in our daily lives.  The program only works if I do the work.
3. I commit to total confidentiality within the group. I will not disclose outside of group personal identifying information or stories about other group members. This includes sharing with my partner, family members, or friends. If sending email or texts, I will use extra precaution to seek permission with the recipient of the message before sending correspondence using either method. I will also not talk about other group members with a fellow group member. If I am concerned about the safety of a fellow group member, I will contact the facilitating therapist immediately. Failure to abide by confidentiality rules will cause me to be removed from participation in the group.
4. I understand that if I disclose the abuse of children, the elderly, or disabled, or report suicidal or homicidal feelings and/or intentions, the group therapist will be required by law to report such information to legal authorities.
5. I will challenge myself to open up and share on a personal level. I realize that the group will be more helpful to me if I learn authenticity. I will be honest with my feelings.
6. I realize that group therapy will never provide the necessary social interaction that will be found outside of the group. I will reach out to other participants outside of the group to get the support I need.
7. I will not bring children to the group.
8. I will not bring any type of firearm or weapon to the group.
9. I agree to have no sexual contact with other group members, nor to engage in solicitous behavior. Failure to abide by this agreement will cause me to be removed from participation in the group.
10. I will take responsibility for my own work. I understand that healing is an individual process that requires honesty and consistency.
11. I realize that group participation is not intended to meet all of my individual psychological and emotional needs. I will seek out individual therapy when needed. I understand that Family Strategies Counseling Center encourages participants to have a primary therapist to assist if the need for additional help may arise.
12. I understand that Family Strategies Counseling Center encourages participants to seek spiritual support from ecclesiastical leaders. The group does not impose spiritual or religious agendas.
13. Family Strategies utilizes E-therapy (teletherapy) services which are HIPAA compliant for security and confidentiality. However, I realize that there are limitations and risks associated with E-therapy, including inherent confidentiality risks of electronic communication and potential for technology failure. If there is an emergency and the therapist is unavailable, I should call 9-1-1.
14. Family Strategies does not allow either the counselor or client to record any portion of video or telephonic therapy sessions unless prior consent has been obtained in writing for the purpose of training or supervision.

I have read and agree to the above conditions. I understand the information and my questions were discussed with me by the class instructor. I understand that I can leave the class at any time for any reason. By signing this consent, I agree to accept the risks of participation in the SABR Maintenance Class.

1. I understand that I must register online for one GROUP at a time.
2. I understand that this fee is non-refundable and non-transferrable.