Process Group Informed Consent

LPC-Associate Process Group

peacefullifecounselinghello@gmail.com

Informed Consent


Courtney Milligan, LPC-Associate

supervised by Lacie Hamilton, LPC-S

Messina Delgado, LPC-Associate

supervised by Stamatis Bogdanos, LPC-S


Statement of Professional Disclosure:

We are LPC-Associates with separate LPC-S clinicians as our professional supervisors. 


Counseling Relationship:


Group processing for LPC-Associates will involve a group of people who are likely experiencing similar challenges in the period of their lives. The aim is to provide a space to get together to share their successes, challenges, and resources with the goal to give and receive support from each other.
We make sure to maintain a safe environment that is conducive both for sharing and accepting each other where all can grow and trust one another and where everyone will feel respected and valued.

  • CONFIDENTIALITY
    We respect each and everyone’s right to privacy and confidentiality. Due to the nature of groups, we can not guarantee confidentiality. Due to this being a processing group, not supervision or consultation, we ask you to refrain from sharing any specific details about clients or cases you encounter in your own work. Hosts aim to maintain privacy and confidentiality of group members and ask group members to do the same.

However, please understand that confidentiality is not absolute and is limited by law. Certain limitations are as follows:

  1. Threatening one’s self or another that may result in physical harm;
  2. An act of physical or emotional abuse against a child, elder, or any person;
  3. Whenever we are summoned by court order to disclose information against a participant. However, we shall notify you.
  4. Your prior written consent to release records.
  • CONDUCT AND RELATIONSHIP
    For safety it is necessary that the following is required to be complied with by its members:
    1. Discussions made within the group session are not allowed to be discussed outside with anyone and should maintain the practice of confidentiality in order to build trust with fellow members;
    2. Members should maintain positivity and not induce disrespect among others;
    3. Members should not be drunk or under the influence of other drugs;
    4. Maintain conduct that brings respect to fellow members’ thoughts, emotions, or behavior.
  • THE HOST(S)
    The process session leaders should maintain a professional relationship with the participants all the time and no more than that. Any relationship with a participant may result in a “dual relationship” and may affect the goals of the session.
  • WHAT TO EXPECT
    The sessions consist of processing the issues that a member is involved with such as challenges to being an LPC-Associate, resources, sharing counseling related information, self-care for counselors, etc, where the others will give their feedback and reaction towards the said issue. The aim is to help LPC-Associates with insight and personal growth.
  • CONSENT
    I agree to adhere to the norms and expectations for group therapy as indicated above. I acknowledge that I have had the opportunity to ask questions and such questions were answered clearly and to my satisfaction.

Liability Waiver: 

This waiver of liability includes any risk of attending Peaceful Life Counseling sessions, engaging in virtual sessions, coaching or attending any events, workshops or other services provided by or recommended by Peaceful Life Counseling and associates. Please see the detail below:

For and in consideration of the receipt of information and counseling services from Courtney Milligan and/or a counselor provided by Peaceful Life Counseling, PLLC, the undersigned, being legally competent and fully authorized and empowered to do so, does hereby RELEASE, ACQUIT, AND FOREVER DISCHARGE PEACEFUL LIFE COUNSELING, PLLC AND ALL PARTICIPATING COUNSELORS, employees, agents, supervisor, contractors, co-hosts, and associates (each a “released party”) connected with, from any and all actions, courses of action, claims, demands, injuries, damages, costs, loss of service, expenses and compensation, on account of any and all known and unknown personal injuries, mental anguish or agitation, and damage claims to person or property resulting from or arising out of or related to counseling services provided by Peaceful Life Counseling, PLLC and its agents, representatives and/or employees in any way affecting the undersigned parties.  I, my heirs or legal representatives forever release, waive, discharge and covenant not to sue Peaceful Life Counseling, PLLC, associates, employees, and release party for any claim caused by any negligence or other acts of a released party.

The undersigned further agrees to indemnify, have and hold harmless Peaceful Life Counseling, PLLC and released party from any and all claims and damages of every kind to any person or property arising out of or attributed to the financial, spiritual, psychological, physical, financial and/or mental health problems which brought the undersigned to Peaceful Life Counseling, PLLC, or to the undersigned for any and all matters relating to or connected with the circumstances for which counseling is sought at any point after the date of this release.

It is further understood and agreed that this waiver and release constitutes an admission and

acknowledgment by this undersigned that they have received no warranty, guarantee, or promise of any particular result either expressed or implied, from Peaceful Life Counseling, PLLC, associates, employees, contractors, or parties that referred you here. The undersigned parties acknowledge and agree that the very nature of their problem(s) is necessarily such that no specific result(s) can be promised or warranted by any counseling services.

This release contains the entire agreement between the parties hereto, and the terms of this

waiver and release are contractual and not mere recital.

Participation in yoga and/or somatic movements involves exercise. Exercise can result in accident or injury. I assume the risk connected with participation in yoga and/or somatic movements and represent that I am in sufficiently good health and condition and suffer from NO physical or mental impairment which would put me at risk of injury while receiving yoga and/or somatic movements instructions. I am aware that my participation in the activities could result in high blood pressure, fainting, heartbeat disorders, physical injury, heart attack or stroke or other concern and may aggravate pre-existing injuries. I understand that I could experience muscle, back, neck and other injuries as a result of my participation in the activities. I understand my physical limitations and I am sufficiently self-aware to stop or modify my participation in any activity before I become injured or aggravate a pre-existing injury. In consideration of being permitted to participate in the activities, I agree to assume full responsibility for any risks, injuries, or damages, known or unknown, which I might incur because of participating in the activities including those which may result from the negligence of Peaceful Life Counseling, PLLC, associates, contractors, and employees. I specifically agree that Peaceful Life Counseling, PLLC, the facilitator and instructor of the classes I am participating in, and/or released party shall not be liable for any claim, demand, cause of action of any kind resulting from or related to my use of the facilities or instruction provided by Peaceful Life Counseling, PLLC, released parties, or their referrals, mentions, or recommendations to other providers. I understand that any referrals, mentions, or recommendations to other providers, services, supplements, or other resources require my own due diligence, my own decision to contact and meet said providers, and are done under my own free will and are voluntary. I agree to indemnify, have and hold harmless Peaceful Life Counseling, PLLC, associates, contractors, employees, and any released party from any and all claims and damages of every kind to any person or property arising out of or attributed to any outside services and/or providers that may be discussed, mentioned, or referred to within my own counseling sessions. 

The undersigned further states they have carefully read the foregoing release, know the

contents thereof, are fully competent, and sign the document as their own free act and deed.


Online Meetings:


All sessions will be online. 

There are risks, benefits, and consequences associated with telehealth, including but not limited to: disruption of transmission by technology failures, interruption and/or breaches of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies. 

Recording of sessions or any portion of sessions is not permitted by any party. All information disclosed within sessions and written records pertaining to those sessions are confidential and may not be disclosed to anyone without written authorization, except where the disclosure is permitted and/or required by law. 

During a telehealth session, we may encounter technical difficulties resulting in service interruptions. If this occurs, end and restart the session. 

Meetings may not take place in moving vehicles or in places that are unsafe or that may compromise your privacy. By joining the meeting, you agree to be in a safe environment, where all group members’ privacy may be maintained.

Fees:

There are no mandatory fees associated with joining this group. If you are inclined, donations for the hosts’ time are accepted. 

Code of Conduct:


We are legally required to follow the American Counseling Association’s Code of Ethics and the rules and regulations set forth by the Texas Behavioral Health Executive Council for Licensed Professional Counselors. You may request a copy of the Code of Conduct or view the document at https://www.counseling.org/resources/aca-code-of-ethics.pdf


I have read and agree to the information provided in this document. By participating in this group, staying in the telehealth session, and/or providing my email to sign up for the group I have agreed to these terms and informed consent.