TRS Group Consent Form

Understanding Group Therapy at Tewa Roots Society

Group therapy is a process of understanding more about yourself and others in a safe environment. Tewa Roots Society Basecamp groups will use creative methods to explore building regulation and coping skills, and expressing and processing emotions through art based activities, movement and breathwork, and other processes. We will explore topics together such as healthy relationships, communication skills, anger management, and building identity and resiliency. Group members will not be forced to share more than they are comfortable with, and will learn ways to support each other through difficult times. If at any time you feel uncomfortable or unsafe in the group, please let one of your facilitators know. Your facilitators are there to create a safe space and support you.

Knowing the Risks of Group Therapy

There can be discomfort involved in participating in group therapy. You may remember unpleasant events, or experience feelings of anger, fear, anxiety, sadness, frustration, loneliness, helplessness, or other unpleasant feelings. If these distressful emotions arise during your therapy, please talk with your group and with your group facilitator.

Group Member’s Agreement for Confidentiality

All members of the group will be asked to agree to a high level of confidentiality in the group sessions. It is appropriate to share your personal reaction and feelings about group with others, but please do not share other people’s stories with anyone outside of the group.

Confidentiality and Limitations

Confidentiality of information conveyed in groups is highly important and honored by all personnel at Tewa Roots Society. Certain legal and ethical limitations to confidentiality must be acknowledged and addressed. Counselors at Tewa Roots Society are expected to consult with other professionals regarding the group and/or seek supervision. Your information may be disclosed to third-party payers only when you have authorized such disclosure, such as paying for services through an insurance company. State law mandates the reporting of any suspected abuse or neglect of children or vulnerable adults. Mandatory reporting is also required for situations in which a client is at risk of ending their own life or the life of somebody else. Mental health records may be legally subpoenaed, in which case a judge could require Tewa Roots Society to release client information. You may also request records be shared with other healthcare providers for coordination of care. This would require you to sign a release of information form. Provision of records may take up to 30 days. 

Consent to Bill Insurance

This consent must be completed to use your insurance benefits to pay for groups at Tewa Roots Society. Tewa Roots Society’s fee will be changed to the negotiated fees for these insurance companies only. These contracted insurance plans require that Tewa Roots Society submit the insurance forms directly to them. If you consent to use your coverage for this service, your insurance company will be allowed to have access to your medical records and mental health information. 

Release 

If I am using my insurance, I hereby grant permission for Tewa Roots Society to disclose information regarding this treatment to my insurance company, managed healthcare network, and/or my employee assistance program. This may be done to assist in the management of the care and for the evaluation and administration of my claims, as appropriate.

Assignments

I authorize payment of medical benefits to be made directly to Tewa Roots Society for services rendered.

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Client's First and Last Name *
Client's Medicaid ID (N/A if not applicable) *
Client's Group Number (N/A if not applicable) *
By signing below, I am agreeing to the following statements: 

I have read, understood, agree to, and consent to the conditions of joining a Tewa Roots Society group outlined in this consent form. 
Electronic Signature of Client: *
Electronic Signature of Parent/Guardian: *
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