Please review the terms of the Agreement and then complete the form below it.

Only fill out this form if you were already instructed to by our staff. If you are a new or existing client expressing initial interest in our groups, fill out this form instead.

General Terms

This form documents that I agree to participate in the Healthy Minds Series program at Insight Psychological Group in accordance with the following rules and policies.

The Healthy Minds Series consists of therapeutic group courses lead by licensed clinicians in the State of New Jersey authorized to provide psychotherapy and counseling as well as psychoeducation and support services. The groups are elective courses designed to provide education, develop skills, and create connection between co-participants. Participants are not diagnosed or treated for any particular disorder during the courses. As such, the Healthy Minds Series at IPG is not covered by insurance, and I agree to pay the fees charged by IPG for the groups, as stated in the Payment Authorization in Section II below.

While I expect therapeutic and educational benefits from the groups courses I attend, I fully understand that no particular outcome can be guaranteed. I understand that I am free to discontinue my attendance at the groups at any time but that it would be best to discuss any plans to end my participation before doing so with the group leader.

I have been informed about and understand the foreseeable benefits and risks of participation in the group course(s), as well as possible alternative methods of addressing the problems I am struggling with. I understand that participating in a collaborative group process of learning around emotional subjects can sometimes cause upsetting feelings to emerge, that I may feel worse temporarily before feeling better, and that I may experience distress caused by changes I may decide to make in my life because of the groups.

I understand that the group leader cannot provide emergency services. I understand that in any emergency, I may call 911 or go to the nearest hospital emergency room. I also understand that I may avail myself of psychotherapeutic treatment at IPG or with any other mental health care provider, concurrently or instead of participation in the Healthy Minds Series, whether or not my group leader has advised me to seek out such treatment.

I understand that I have a right to ask the group leader about his or her training and qualifications and about where to file complaints about the group leader’s professional conduct.

I understand that group facilitators reserve the right to mute or expel any participants from groups deemed inappropriate for group process work or for participating in overly disruptive behavior to the group process. This includes monopolizing conversation, exhibiting symptoms of severe mental illness, violence and/or threatening or demeaning behaviors.

If a participant is expelled, the group facilitator will reach out to them to discuss termination or referral to an appropriate health care provider.

Confidentiality and Ground Rules

I understand that the group courses of the Healthy Minds Series are private and confidential. The group leader will not disclose any personal or private information about me. I understand that while I cannot directly control or prohibit the other group participants from disclosing my personal information outside of the group setting, I nevertheless agree to uphold the privacy and confidentiality of the other co-particpants in the groups, on the condition that that they uphold the privacy and confidentiality of my personal information, and likewise sign this agreement. Nevertheless, I assume the risk to my privacy and understand that neither the group leader nor IPG can be held responsible for other group members revealing confidential information.

In order to ensure the highest degree of privacy, I understand that all group participants will agree to the following rules:

1. Only first names will be used at group sessions.
2. I will not socialize with other group members outside of sessions.
3. I will not discuss any information about a group member except with other group members during therapy sessions.
4. There will be no visitors at, nor recordings of, group sessions allowed.

There are some exceptions to the group leader’s responsibility to maintain the confidentiality of the participants’ information, as follows:

1. The group leader is required by law to report suspected child abuse or neglect to the proper authorities.
2. If I tell the group leader I intend to harm another person, the group leader must try to protect that person, including by telling the police or the person or other health care providers. Similarly, if I threaten to harm myself, or my life or health is in any immediate danger, the group leader will try to protect me including by telling others such as my relatives or the police or other health care providers who can assist in protecting or assisting me.
3. If I am involved in certain court proceedings the group leader may be required by law to reveal information about me. These situations include child custody disputes, cases where a group participant’s psychological condition is an issue, lawsuits or formal complaints against the group leader, civil commitment hearings, and court-ordered treatment.

In all of the situations described above I understand that the group leader will try to discuss the situation with me before any confidential information is revealed and will reveal only the least amount of information that is necessary.

Participant Information

The above individual will also be the party responsible for all payments, unless specified with our office.

Payment Authorization and Consent to Participate

The fee for each group is $65 per person, per session. This fee will be charged to the card on file following each session. Participants are required to commit to participation in the full length of each course. However, each participant is allowed to skip up to two group sessions, per each course, for any reason, with at least 24 hours advance notice to the group leader. This means that the minimum amount agreed to is $390 for 6 sessions out of an 8 week course. If all 8 sessions are attended, the total cost for that individual will be $520. (In cases of hardship, the Director of IPG may allow for a reduced rate to attend the group courses. Such allowance will be provided in writing or by email.)
Please indicate your consent by checking each item below.