WILCO IRIS and NMRW Support Group- Informed Consent 
Thank you for your interest in our LGBTQIA+ student support group and the opportunity to work with you as a guide in your group counseling process. The purpose of this document is to provide you with a summary of the policies and informed consent that guide your work with New Moon Rising Wellness. Your responses will also help us understand topics participants want to explore so we can create a space that feels supportive, comfortable, and meaningful for everyone. This group is meant to be a safe, comfortable and fun space for YOU! Your voice and opinion matters!
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NAME  *
PRONOUNS
DATE OF BIRTH *
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EMAIL (to receive updates about scheduling) *
EMERGENCY CONTACT (Name, relationship, phone number)  *Will only be used in event of emergency* *
This FREE Support Group will be hosted from 4:30pm-6pm on Mondays at New Moon Rising Wellness, 1650 Murfreesboro Road, Suite 240, Franklin, TN, 37067
Please indicate below which dates you believe you will attend this support group (its okay if this changes over time):
Qualifications and Counseling Background

Megan Thomas is a Licensed Professional Counselor, Mental Health Service Provider (LPC, MHSP) in the state of Tennessee at New Moon Rising Wellness. She holds a Master of Arts in Counseling Psychology. As the Director of Learning and Development at New Moon Rising Wellness, she also provides supervision for Master’s Level Counseling Interns (Addy and Andi) who will also serve as guides for your support group process.

The New Moon Rising Wellness approach to counseling is based upon person-centered, somatic, and cognitive-behavioral theories. We strongly believe that each individual knows themselves best. Our approach to group therapy and support groups is to guide participants in their journey of finding themselves and improving quality of life. We create a safe, non-judgmental environment to help you learn new skills and manage your mental health.

Our New Moon Rising Wellness philosophy is to be inclusive and mindful of the diversity of everyone who comes through our doors.  We are passionate about building community where mental matters and equitable care is accessible to all races, ethnicities, abilities, socioeconomic statuses, ages, sexual orientations, gender expressions, religions and cultures.

Confidentiality

Tennessee state law and ethical requirements of the State Board indicate that what is discussed in our counseling sessions is privileged communication. This means that you control the release of information to a third party. I will not tell anyone else what you have told you, or even that you are in therapy with me, without your written permission (aside from certain circumstances mentioned below). You may direct us to share information with whomever you choose and that permission can be revoked at any time.

There are several limits to confidentiality that require me to release information in order to keep you and/or others safe from harm. These limits include:

1. If we have good reason to believe that you will harm another person, we must attempt to inform that person and warn them of your intentions. We must also contact the police and ask them to protect your intended victim.

2. If we have good reason to believe that you are abusing, inflicting psychological harm, or neglecting a child or vulnerable adult, we must inform the Department of Children’s Services and the police within 48 hours. This also applies if you give me information about someone else who is doing this.

3. If we believe that you are in imminent danger of harming yourself, we may legally break confidentiality and call the police, mobile crisis, or someone else who can ensure your safety.

4. If you are involved in a court proceeding and a request is made for information concerning our professional services, such information is protected by the therapist-patient privilege law. We cannot provide any information without your written authorization, or a court order.

Due to Master’s Level Counseling Interns being under supervision by both Megan Thomas and their university advisors, we may share medical records for consultation purposes with supervisors and our group practice owner, Kim Rate, LPC, MHSP.  All counseling supervisors including Megan and Kim and university supervisors, are bound by the same rules of confidentiality.


Communication and Social Media Policy

We have professional accounts on Facebook and Instagram in order to share information and practice updates with other social media users. We recommend that you only follow these professional sites if you are comfortable with your name and information being connected to our counseling practice. We do not require any clients/participants to follow our professional accounts, and we do not request testimonials, ratings, or endorsements from clients/participants on these sites. These sites are not places for personal discussion concerning therapeutic issues, either through wall postings or private messages.

We will not follow or contact any former or current clients on any social networking site. Adding participants as friends on these sites can compromise your confidentiality and the therapeutic relationship.


Informed Consent

Please feel free to discuss with Megan Thomas, LPC, MHSP any of the policies and processes outlined above. It is important that you clearly understand your rights and responsibilities when entering into a counseling relationship.

By your signature below, you are indicating that you have read, understood, and agree to the contents of this document and at this time choose to pursue support group services with Megan Thomas, LPC-MHSP and her Master’s Level Counseling Interns. 


ACKNOWLEDGMENT OF INFORMED CONSENT
Participants under the age of 18 must have permission from a parent or legal guardian in order to participate in this group. A parent or legal guardian is required to review and sign this consent form before any minor participant can attend group sessions. This helps ensure that guardians are aware of the nature and purpose of the group and give permission for their child to take part. For participants who are 18+, you must review and sign the consent form before attending group sessions. Participation cannot begin until this consent has been received.
By signing below you acknowledge that you have read and understand the information in this section. *Name and date required as e-signature* *
PARENT(S)/LEGAL GUARDIAN(S), By signing below you acknowledge that you have read and understand the information in this section, and consent to your child participating in this group.  (Students under the age of 18)  *Name and date required as e-signature*
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