EmpowerHER

Informed Consent for
Participation in Group Therapy, Adults 18+
Gabriella Pelosi, Licensed Mental Health Counselor, PLLC

Purpose of Group Therapy:
Group therapy provides an opportunity for participants to share their experiences, learn from others, and receive support in a group setting. The purpose of this group is to facilitate personal growth and address specific issues that affect the participants.

Nature of Group Therapy:
Group therapy involves discussing personal experiences, thoughts, and feelings in a group setting. The sessions will be led by Gabriella Pelosi, Licensed Mental Health Counselor (the “Counselor”). There may be times Gabriella invites a guest speaker, specialist or peer to join her to offer further expertise and support to the group. While the Counselor will work to create a safe and respectful environment, the nature of group therapy is such that confidentiality cannot be fully guaranteed among group members.

Confidentiality Disclaimer:
Counselor Confidentiality: The Counselor is bound by professional ethical standards to keep all information shared during group therapy sessions confidential. However, there are legal and ethical limits to this confidentiality, including but not limited to:
● If the Counselor believes there is a risk of harm to oneself or others.
● In cases of suspected abuse or neglect of a minor.
● If required by law or court order.
Group Members' Confidentiality: While group members are encouraged to respect the privacy and confidentiality of others, the Counselor cannot guarantee that other group members will maintain confidentiality. Participants are advised and encouraged to share only what they feel comfortable sharing and to respect the confidentiality of other group members.

Nature of Sharing:
By participating in group therapy, participants may hear others’ personal stories and share their own. Participants are encouraged to be respectful and avoid sharing details of the group's discussions outside the group setting.

Participation and Voluntary Consent:
Participating in facilitated group sessions with Gabriella Pelosi, LMHC (the “Counselor”) does not establish a therapeutic relationship between you and the Counselor. While the Counselor and other facilitators of group sessions are trained professionals, the information and guidance provided in these sessions are intended for educational and support purposes only.

It is important to note that a therapeutic relationship is formed through mutual agreement between an individual and a counselor, typically in a one-on-one setting. Participating in group sessions, while beneficial for personal growth and support, does not substitute for the individualized attention and confidentiality of a formal therapeutic relationship.

Furthermore, any information shared within the group setting should be considered as general guidance and not personalized advice. Confidentiality within group sessions is limited to the extent permitted by law, and participants should exercise caution when sharing sensitive information.

If you require individualized therapeutic support, you are encouraged to seek out a licensed counselor or Counselor for individual sessions. The Counselor is able to provide referrals and assistance in finding the appropriate support for your needs.

Participation in group therapy is voluntary. Participants may withdraw from group therapy at any time. Should a participant cause a disruption to the group format, setting, or conversation, they may be asked to leave and not return to the group. A refund will not be provided in cases of voluntary withdrawal or being asked to leave by the group facilitator. They may or may not be welcomed back to future group therapy sessions.

Benefits and Risks:

Benefits:
● Group therapy can provide a supportive environment, reduce feelings of isolation, and offer new perspectives and coping strategies.
Risks:
● Participants may feel discomfort when discussing personal issues or hearing others' stories.
● There is a possibility that others may not respect the confidentiality of the group's discussions.
● Participants may know other participants in the group from outside of the group itself.

Consent:
By signing this form, I acknowledge that I have read and understood the information provided above. I understand the nature, purpose, risks, and limitations of group therapy. I agree with the terms outlined above. By participating in facilitated group sessions, I agree to abide by the guidelines set forth by the Counselor.

Thank you for your understanding and cooperation.