Please give information, as applicable, about the quality of your relationship to people close to you. Use as much space as you need.
5. Others(Please Specify)
Check all the statement(s) below that apply to the type of family you grew up in:
Please list significant medical problems/conditions, and indicate if you are receiving treatment for them; if none, write "na":
Do any of these problems affect your everyday life? If yes, how is it affecting you?
Briefly describe any surgeries or hospitalizations for serious illness or injuries (What, where, when, etc.), if none, please write "na".*
Have you ever blacked out / lost consciousness and/or experienced any type of serious head injury or trauma? If so, please indicate when and what happened. If none, please write "na".*
Are you on prescribed medication? If so, please give details of the medication: 1.who is prescribing it, 2. for what condition, and 3. for how long you’ve been taking it. If none, please write "na"*
Do you currently have thoughts of harming yourself? If yes, please describe briefly. If none, please write "na".
Have you ever experienced a problem with alcohol, drugs, or prescription medications? If yes, please describe.
Have you had support or counseling group experience before or currently? If yes, please describe briefly what helped and what did not help.
Please describe in detail the issues that led you to seek out support group. Please use as much space as you would need. How long have you felt this way? What made you decide to reach out now?*
Thank you for your time filling out the form, please read the information on fee, confidentiality and agreements below, sign your name and submit. I look forward to meeting you when the groups are ready.
Regular fee is USD 50 per group session; Minimum of 8 session commitment are required for ideal results. Fees are due be paid to Paypal account email@example.com before the sessions start. 4 people minimum and 8 people maximum per group.
Appointment Cancellation Policy: In the event that you must cancel or reschedule a session, please inform Cecilia as soon as possible through email. You are asked to pay the full fee for each missed session without twenty-four hour notice provided.
Professional Ethics: I, Cecilia Ding, subscribe to the Code of Ethics and Standards of Practice of the American Counseling Association (http://aca.convio.net)，ICF Code of Ethics, Canadian Counselling and Psychotherapy Association.
Member Confidentiality: Everyone at the support group will be asked to keep everything discussed confidential. Group members are discouraged from meeting outside the group until the sessions are terminated.
Confidentiality and Release of Information: In recognition that confidentiality is an integral part of successful relationship, I maintain confidentiality with respect to every aspect of the treatment process, including a client’s name. In no situation, except as is necessary for case consultation with another professional or as required by law, will I reveal any aspect of your personal information. In all other circumstances, release of information requires your express written consent.
Waiver of Liability. From time to time, I attend provide peer guidance and case consultation with my peer group, and general details of cases are shared in this confidential supervision process.
By signing this waiver of responsibility, you release Cecilia Ding from any real or perceived liability arising out of the services provided.
By signing my name and the date below, I agree that I have read the information above and agree to abide by these policies. In the case of any disagreement, conflict or misunderstanding, I agree to work within a mutually agreed mediation process. I will not under any circumstances pursue litigation against Cecilia Ding.