Please read the form below and sign.  Your signature indicates that you understand and agree with the content of this form. 

Your participation in the group will be confirmed upon the receipt of your payment/down payment along with the submission of Group Readiness Form and the Informed Consent Form found under the "ABOUT" tab.  If filled out here, this form will be electronically submitted.  

Please read the information and sign below.


This is a psycho-educational experience. This means that you will be experiencing interplay between education, and personal processing and growth.  This process is presented as an intensive weekly group setting.   Participation in this experience can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek attendance at a psycho-educational process.  

During the psycho-educational process you may also encounter unpleasant feelings or thoughts.  You may also make decisions about changes you would like to make in your behaviors and/or relationships.  This experience may result in changes that were not originally intended.   

During the course of a psycho-educational process, your facilitators will draw on Dr. Brené Brown’s shame resiliency theory. Attending a psycho-education process is not a substitute or alternative for individual psychotherapy or inpatient psychotherapy. If you are in need of names of counselors before, during, or after the psycho-educational process, your facilitator will be happy to provide you with a list of providers.  

I understand that I am agreeing to participate in a psycho-educational experience that carries with it the potential of positive benefits and/or unpleasant feelings.  I understand that I may experience both expected and unexpected change.     

I understand that this is not considered, nor a substitute or alternative for individual/couple counseling, and that I am free to participate in my own counseling during, or after this experience.  

I understand that this group experience will not provide emergency or crisis services. If needed, the facilitator can give a list of needed resources.

I also agree to practice self-care while I participate in this group.   If I am feeling overwhelmed, I will slow down, or take a break and step away. 

I understand that I am free to participate to whatever degree is comfortable for me, and I will not push myself beyond that to meet any perceived expectations of myself or others.

I understand that Sylvie Smith, RP, ICADC, CDWF (candidate), group facilitator will follow the law of therapy and confidentiality in Ontario including the exceptions below. Your psychotherapist is required to break the confidentiality:

  • If during your sessions you give any information that would lead your psychotherapist to believe that you may hurt yourself, someone else, or someone may hurt you in any way, your therapist will notify the appropriate authorities to prevent such actions from taking place.

  • If during your sessions you give any information that would lead your psychotherapist to believe that there is neglect or abuse of a minor, your therapist will notify the appropriate authorities to prevent such actions from taking place.

  • If during your sessions you give any information that would lead your psychotherapist to believe that a regulated health professional has been involved with sexual abuse, your psychotherapist will notify the appropriate authorities to prevent such actions from taking place.

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