As a group member, I have rights and benefits as well as duties, and I understand that some of them are described in this agreement.
This group Making Peace with Food: Mindfulness Skills to Overcome Overeating will meet from 6:00 to 7:30 pm on October 24th, October 31st, November 7th and November 14th 2013 at 11 Main St, Suite 2, Kennebunk.. The total cost of this group is $120. I agree to pay this fee in full (even for group meetings I do not attend) by the October 18th deadline. Please make checks payable to Linda J Cooke.
The purpose of this group is to provide me with the opportunity to achieve the following goals:
Learn the benefits of how mindfulness and body awareness practices can help me overcome compulsive eating throughout my day.
Learn how to regulate my emotions so that I don’t turn to food and mindless eating to regulate my feelings.
Increase awareness of what will feed and nourish my body through practicing breathing and mindfulness skills for self-soothing.
Develop a plan for lifestyle changes that will support a more mindful path to making peace with food
I agree to participate in this group by openly talking about my thoughts and feelings, honestly reporting my behaviors, keeping my promises, and exchanging helpful feedback with other members of the group.
I will attend all meetings of this group from start to finish, even if I do not always feel like it. If I cannot attend, I will tell the group a week in advance (at the beginning of that meeting), or, if it is an emergency, call Linda J Cooke, LCSW as soon as I know I cannot attend. If I decide not to go on or am unable to go on with the group, I will discuss my reasons with the group and Linda.
I understand that this group experience is not a replacement for individual therapy. If issues arise that are not suitable for the group's process, I may benefit from individual therapy sessions, for which I will have to pay separately from the cost of the group sessions.
I understand that Linda J Cooke, LCSW is required by law to report any suspected child or elder abuse, or serious threats of harm to myself or another person, to the proper authorities.
With full understanding of the need for confidentiality (that is, privacy) for all group members, I accept these group rules:
1. We will use only first names.
2. We will permit no children, spouses, journalists, or other visitors in our sessions.
3. We will not permit any kind of recordings of our sessions, even by our members or group leader.
4. I promise to tell no one the names of the group members or in any other way allow someone not in the group to learn their names.
5. I promise not to tell anyone outside the group of any of the problems presented by any group member, even if I conceal the name of the member.
6. I understand and agree that if I break rules 1– 5 often without meaning to, or if I ever break one of these rules on purpose, I will be asked to leave the group.
7. I understand and agree that Linda J Cooke, LCSW will keep a record on each individual member, and that this record will not contain information by which any other members can be identified. This record, kept in each member's name, can be shown to other professionals only with the member's written consent.
8. I understand that Linda J Cooke, LCSW will keep another record about the group's meetings and the interactions of the members, and that this record will not be included in any member's records. This record may not be shown to anyone without the written agreement of all the members and Linda J Cooke, LCSW.
9. Please arrive on time but not more than 5 minutes prior to group starting.
10. Please plan on staying for the entire group.
11. Please turn off your cell phone before entering the waiting room
I have read the points stated above, have discussed them when I was not clear about them, and have had my questions answered fully. I understand and agree to them, as shown by my signature below.