Body Image Therapy Group (Spring 2024)

Dates: Wednesday's 6:30 - 8:30pm (May 1 - June 5) 

Location: Bethlehem Centre (2371 Arbot Rd) - Tabor Room

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Housekeeping
Thanks for taking the time to give me some of the basic info plus review and sign the appropriate forms.

If you have any questions about any of the information I'm collecting OR forms below, please feel free to email me at gillian@superyou.ca.
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Phone number (cel)
Preferred email
Emergency Contact Name
Emergency Contact Phone Number 
Relationship
Group Objectives
The intention of this group is to offer some ideas/ information/ education about body image, and to help you explore the relationship you have with your body. We will be exploring broader themes of diet culture, sexual objectification, stress, trauma,  and how these issues have impacted our collective relationship with body. We will also spend a significant amount of our time together exploring evidence-based concepts, perspectives, and strategies known to support and encourage body peace. 

This group will be part "psycho-educational" and part "group counselling." You will be encouraged to engage, but are not required to share. The impact of trauma history on body image will be discussed, and while discussions surrounding the impact of trauma history may be supportive of healing, this group is not the place for individual processing of trauma. Should additional support be required, recommendations and arrangements will be made. 

This group is for folks who...
  • Struggle with body image or self-esteem
  • Compare themselves to others
  • Experience anxiety related to their appearance
  • Have difficulties with relationship with food such as restriction, binge eating, or emotional eating*
  • Identify as a woman or non-binary folks who identify with the struggles associated with being mis-gendered as a woman
*Due to the nature of this group, it is understood that disordered eating and/or eating disorder may be part of your lived experience. Please note: this group is not intended as an Eating Disorder (ED) recovery group. While the topics discussed may support recovery, additional support specifically for ED is required if you are in active ED. This group is not appropriate for individuals in active ED who are not medically stable. 

If you are unsure about your suitability for this group and would like to have a phone chat to determine the suitability of this group for you, please use this link to set up an appointment. 

I understand the group objectives and feel as though this group will be a good fit for me. *
If you're not sure, or if there is any trauma or eating disorder history you would like me to be aware of prior to the group starting, please share below. 
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Get Active Questionnaire
*this form is related to the embodiment/movement components of our sessions. This form is a standardized form developed to help me help you. 

Please note: all embodiment/ movement practices will be offered in inclusive ways that are available for all bodies. 

Physical activity improves your physical and mental health. Even small amounts of physical activity are good, and more is better.

For almost everyone, the benefits of physical activity far outweigh any risks. For some individuals, specific advice from a Qualified Exercise Professional (QEP – has post-secondary education in exercise sciences and an advanced certification in the area) or health care provider is advisable. This questionnaire is intended for all ages – to help move you along the path to becoming more physically active.
Within the last 6 months have you experienced a diagnosis of/treatment for heart disease or stroke, or pain/discomfort/pressure in your chest during activities of daily living or during physical activity?
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Within the last 6 months have you received a diagnosis of/treatment for high blood pressure (BP), or a resting BP of 160/90 mmHg or higher?
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Within the last 6 months have you experienced dizziness or lightheadedness during physical activity?
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Within the last 6 months have you experienced shortness of breath at rest?
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Within the last 6 months have you experienced shortness of breath at rest?
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Within the last 6 months have you experienced concussion?
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Do you currently have pain or swelling in any part of your body (such as from an injury, acute flare-up of arthritis, or back pain) that affects your ability to be physically active?
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Has a health care provider told you that you should avoid or modify certain types of physical activity?
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Do you have any other medical or physical condition (such as diabetes, cancer, osteoporosis, asthma, spinal cord injury) that may affect your ability to be physically active?
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How active are you currently (NO judgment)
Canadian Physical Activity Guidelines recommend that adults accumulate at least 150 minutes of moderate- to vigorous-intensity physical activity per week. For children and youth, at least 60 minutes daily is recommended. Strengthening muscles and bones at least two times per week for adults, and three times per week for children and youth, is also recommended.
Would you say you are currently meeting these guidelines? (again, no judgment)
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General advice for becoming more active 
If you're not currently meeting the activity guidelines the goal is to increase your physical activity gradually over a period of some weeks.

If you want to do vigorous-intensity physical activity (i.e., physical activity at an intensity that makes it hard to carry on a conversation), and you're not currently achieving 150 minutes per week of activity make a point to reach out to Gillian prior to starting to ensure the steps you're taking are a good choice for you! This can help ensure that your physical activity is safe and suitable for your circumstances.
Which option below most accurately describes your status with regards to becoming more active:
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Informed Consent (physical activity)
I understand the potential risks involved in participating in physical activity. I assume the responsibility and risks as explained to me. I understand that participating in a physical activity program may include, but not be limited to, serious bodily injury, heart attack, stroke, or even death. I consent voluntarily to participate in an exercise program based on the information provided to me.
I agree to above informed consent (physical activity)
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Liability Waiver (physical activity)
I certify and acknowledge:

That Gillian Goerzen/ Super You Fitness & Nutrition Coaching ("Super You") has advised me prior to my commencement of participation in cardiovascular and resistance training programs that such participation could result in physical injury.

That I freely and knowingly assume the risk in such programs, and I hereby waive any right, claim, or cause of action against Gillian Goerzen or Super You and release her and/or her company from any liability for any injury, cost, damage, expense or claim, which I or anyone on my behalf might incur as a direct or indirect result of my participation in this cardiovascular and resistance-training program.

That I have read this Liability Waiver form, understand and agree with each of the foregoing points, and have received a copy a copy of this release form on this date.
I agree to the liability waiver
Informed Consent (Group Counselling)

Professional Qualifications: I am a Registered Clinical Counsellor (#22774) and am trained in a number of different counselling and therapy techniques. A Registered Clinical Counsellor (RCC) is regulated by the BC Association of Clinical Counsellors. As criteria for membership, Registered Clinical Counsellors must meet rigorous academic requirements at the Masters level, along with clinical experience and supervision requirements. I have completed specialized training in addition to my graduate studies, some of which include: Satir Transformational Therapy (Level 1), Accelerated Resolution Therapy (ART), Internal Family Systems (IFS), and Embodiment in Psychotherapy.

Benefits and Risks of Counselling: Some benefits of therapy include a better understanding of yourself and others, your values, goals, and needs. It can also help you understand and improve patterns of learned behaviour and coping mechanisms. Therapy can help you learn to better manage yourself, your wellness, and your relationships. ​​While there are potential therapy benefits, success is not guaranteed and there are potential risks. Therapy may stimulate memories, and evoke strong feelings. Changes in awareness may alter your self-perception and ways of relating to others. For some clients, they may feel worse before they feel better. Therapy is a collaborative process and I invite you to continually discuss any concerns or questions you are having with me.

What is Group Counselling? The format of this retreat will incorporate group therapy sessions that will include opportunities for exploring themes and topics relevant to your relationship with your body. These sessions will include the sharing of information, experiential exercises, dialogue regarding personal experiences and insights. Confidentiality amongst group members will be expected, unless an exception to that rule occurs for reasons outlined above.

Confidentiality: With a few exceptions, you have the absolute right to confidentiality in your therapy. I cannot share any identifying information about you unless you provide written consent and you can revoke that at any time. Please be aware that email may not be confidential as it is stored by our Internet providers.

Exceptions to Confidentiality: 

  • If there is a reason to believe that a child or vulnerable person needs protection from abuse of any kind.
  • If there is a reason to believe that you are going to harm yourself or somebody else that you have identified to me.
  • If a valid court order or a subpoena was served.

By checking this box, you consent to having reviewed the information above and understand the limits to confidentiality
By typing your name below you are signing the above documentation.
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