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MeckHope Consent

Therapeutic Group Informed Consent | MeckHope/County Funded Groups

The SPARC Network provides therapeutic groups as a powerful and valuable method for healing and growth. It is the desire of your group facilitator(s) that you feel safe and experience all the benefits group has to offer. In order to ensure this, we ask that you agree to participate with the following commitment.

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My child have chosen to participate in therapeutic group at SPARC, and I agree to adhere to the following norms and expectations of this group:

  • I agree to keep confidential the names of other members of the group.
  • I will not discuss anything shared in group with others outside of group.
  • I agree to not disclose to anyone outside the group any information that may identify another group member. This includes, but is not limited to, names, physical descriptions, biological information.
  • I will strive to be on time and stay the entire session.
  • I agree to be free of illicit drugs and alcohol, and weapons during group.
  • I will not record group – recording (visually or audibly) in group is not permitted.
  • I agree to turn my phone to “silent mode” or “vibrate” during group sessions.
  • I will notify the group facilitators in advance if I am going to miss a session.
  • I will attend a minimum of 2 consecutive sessions.
  • I will express myself appropriately. I understand that regular ongoing use of profanity will not be accepted, or language that is vulgar, triggering, hurtful or demeaning to others (i.e. ethnic insults, sexual orientation slurs, gender or racial slurs, or offensive spiritual remarks) will not be tolerated.
  • I will not engage in discrimination. SPARC services does not discriminate on the basis of race, sexual orientation, religion, gender, or for any other reason. We welcome into our groups many different individuals from many different backgrounds. We do not tolerate racial, religious or sexual orientation slurs or insults. Doing so is a form of bullying and is not tolerated.
  • I will be respectful of others’ thoughts, emotions, and behavior. It is essential that members know that whatever they say or how they act in group remains in the group and that members will not discuss these things with anyone outside the group. I understand that this is the best way to create a safe and inclusive space and where members can trust one another.
  • I understand that if I am unable to respect the boundaries of the group, I will be asked to leave. I understand and agree to respect the facilitators’ clinical direction.
  • I understand that the facilitators will break confidentiality only under the following circumstances:
    • Indications of harm to self or others
    • Awareness of harm being done to child, elder, or a person with a disability
    • If there is a court order for release of your records.
  • I agree to sign up in advance of attending the group to confirm attendance

In signing this consent form, I indicate that I have carefully read and understand the Therapeutic Group Informed Consent and that I agree to its terms and conditions. I acknowledge that the facilitators have provided the opportunity for group members to discuss and ask questions about the importance and limits of confidentiality and the expectations of the group. I acknowledge that I can withdraw this consent at any time. I acknowledge that I have a choice in who my child receives services from.

The terms of this consent apply to groups conducted in person and/or via a virtual platform.

This authorization is fully understood and is made voluntarily on the part of the undersigned.

I affirm that by digitally signing this form I am the parent/guardian of the child listed above give my permission for my child to participate in the therapeutic group activity with SPARC.

SPARC Staff:_____________________________________________________________________________________________________ Date:_____________