Building From Within: A Self-Worth Process Group

Facilitator: Stephanie Thom, LPC

Group Length: 12 Weeks

Meeting Time: 90 minutes per session

Location: Restore Counseling Therapist office – 1240 Clairmont Rd, Decatur GA 30030

Date: Starting Friday September 11th at 6:00pm to 7:30pm (flexibility on Wednesday if agreed-
upon by the group).

Cost: $75 per group session

Purpose of the Group

Building From Withinis a therapeutic process group designed to help participants explore and
strengthen their sense of self-worth. Throughout the 12-week group, members may explore
topics including self-worth, self-knowledge, self-understanding, self-identity, self-compassion,
self-acceptance, self-love, self-respect, self-care, self-esteem, self-efficacy, and self-
actualization.

The group may include guided discussions, therapeutic exercises, reflection activities,
educational materials, practical coping tools, and opportunities for participants to share and
learn from one another.

Participation in the group is voluntary. However, because the therapeutic process depends on
consistency, trust, and the development of group cohesion, members are asked to carefully
consider their commitment before joining.

1. Twelve-Week Group and Eight-Week Financial Commitment

This group is designed as a 12-week therapeutic experience. Participants are encouraged to
attend all 12 sessions whenever possible

By signing this agreement, I understand and agree to make a minimum financial commitment
of eight (8) group sessions, regardless of whether I attend every scheduled session during that
period.

The cost of the group is $75 per week/session.

Therefore:

• The minimum financial commitment is 8 sessions at $75 per session, for a total minimum commitment of $600.
• If I attend and participate for all 12 weeks, the total cost will be $900.I understand that I am financially responsible for a minimum of 8 sessions even if I miss one or more sessions, arrive late, leave early, or choose to discontinue the group before completing the 8-week minimum commitment
• After the 8-week minimum commitment has been met, any remaining scheduled sessions that I choose to attend will be charged at $75 per session.
• Missing a session does not eliminate my financial responsibility for that session if it falls within my 8-week minimum commitment.
• I understand that fees and payment expectations should be discussed with the facilitator if I have questions before signing this agreement.
• Payments can me made by cash, or by credit card using Ivy Pay which is a secure hipaa compliant mental health payment processing app.

2. Attendance and Participation

Regular attendance is important to the safety, trust, and effectiveness of the group. Each
participant’s presence contributes to the development of the group process.

I agree to:

• Make a good-faith effort to attend sessions consistently and arrive on time.
• Notify the facilitator as soon as reasonably possible if I know I will be absent or late.
• Understand that I may miss important information or group experiences when I am absent.
• Respect the group’s scheduled beginning and ending times.
• Participate at a level that feels appropriate while recognizing that active engagement may support my therapeutic growth.

I understand that participation does not require me to disclose anything before I am ready.
However, I also understand that meaningful participation may involve appropriately sharing
thoughts, feelings, experiences, and reflections.

3. Confidentiality

Confidentiality is essential to creating a safe and trusting group environment.

I agree to respect the privacy of all group members. I will not disclose, repeat, post, record,
photograph, or otherwise share another member’s personal information, identity, experiences,
statements, or participation outside of the group.

This means I agree:

• What is shared in group stays in group. I will not discuss another member’s personal story with family, friends, coworkers, on social media, or with others outside the group.
• I will not identify another group member as a participant in the group without that person’s permission.
• I will not record group sessions in any form without the explicit permission of the facilitator and all participants.
• I will respect each member’s right to privacy.

I understand that the facilitator is ethically and legally required to protect confidentiality but
may be required to disclose information under certain circumstances, including but not limited
to situations involving

• Suspected abuse or neglect of a child, elderly person, or other vulnerable individual when reporting is required by law.
• A serious and imminent risk of harm to myself or another person.
• A valid court order or other legal requirement.
• Other circumstances in which disclosure is required or permitted by applicable law and professional ethical standards.

I also understand that although all group members will agree to maintain confidentiality, the
facilitator cannot guarantee that another participant will never disclose information outside of
the group. If a participant believes confidentiality has been violated, they are encouraged to
notify the facilitator.

4. Respectful and Nonjudgmental Group Environment

This group is intended to provide a supportive environment where members can explore their
experiences without fear of ridicule, hostility, or unnecessary judgment.

I agree to:

• Treat all group members with dignity and respect.
• Allow members to have experiences, beliefs, values, and perspectives that may differ from my own.
• Speak from my own experience by using statements such as “I think,” “I feel,” and “My experience has been.
• Avoid shaming, insulting, mocking, belittling, or attacking another member.
• Avoid arguing with other members in a hostile, aggressive, or disrespectful manner.
• Avoid pressuring another participant to agree with me or disclose information they do not wish to share.
• Listen without interrupting whenever possible. Offer feedback only in a respectful and constructive manner and when appropriate within the therapeutic process.
• Understand that disagreement can occur without disrespect.

The purpose of the group is not to determine who is right or wrong. Members are encouraged
to remain curious, respectful, and open to different perspectives.

5. No Judgment, Criticism, or Personal Attacks

I understand that vulnerability may be an important part of the group process. Therefore, I
agree not to use another member’s disclosures against them.

I will make a sincere effort to avoid:

• Judging or criticizing another member’s personal experiences.
• Giving unwanted advice in a way that dismisses another person’s feelings or choices.
• Arguing for the purpose of proving another member wrong.
• Attacking another person’s character, identity, beliefs, or experiences.
• Using sarcasm, ridicule, intimidation, or hostile language toward another participant.
• Repeatedly challenging another member in a way that interferes with emotional safety.

I understand that the facilitator may redirect conversations, establish limits, address disruptive
behavior, or take other clinically appropriate action when necessary to protect the safety and
integrity of the group.

6. No Dual Relationships While the Group Is Active

To protect therapeutic boundaries and reduce the risk of conflicts, favoritism, discomfort, or
complications within the group process, participants agree to avoid developing new dual
relationships with one another while the group is active.

A dual relationship may include, but is not limited to, developing an additional relationship
outside the therapeutic group such as a close friendship, romantic or sexual relationship,
business relationship, financial relationship, or other relationship that could affect the safety or
dynamics of the group.

While the group is active, I agree:

• Not to pursue romantic or sexual relationships with other group members.
• Not to enter into business or financial arrangements with other members.Not to intentionally develop a new close personal relationship with another participant that may interfere with the therapeutic group.
• To avoid placing another member in a situation that could create pressure, divided loyalties, or discomfort within the group.
• To discuss concerns with the facilitator if I discover that I already have an outside relationship with another group member or if an outside relationship develops unexpectedly.

I understand that group members may encounter one another outside of group. Casual or
unavoidable contact does not necessarily constitute a dual relationship. Participants are
encouraged to respect one another’s privacy and allow each person to decide whether or not
to acknowledge the group relationship in public.

7. Communication Outside of Group

I understand that contact between group members outside of sessions can affect the
therapeutic process and group dynamics.

I agree to use good judgment regarding communication outside of the group and to avoid
interactions that could:

• Violate confidentiality.
• Create exclusion, cliques, or divisions within the group.
• Pressure another participant into unwanted contact.
• Create a dual relationship that conflicts with the group agreement.
• Continue or intensify conflict that occurred during a session.

If concerns arise involving contact between members outside of group, I understand that I may
discuss those concerns with the facilitator.

8. Personal Responsibility and Emotional Safety

I understand that group therapy may involve discussing difficult thoughts, feelings, memories,
relationships, or experiences. At times, participation may bring up uncomfortable emotions.

I understand that:

• I am responsible for communicating with the facilitator when I feel overwhelmed or need additional support.
• I may choose not to answer a question or share information that I am not ready to discuss. I am encouraged to practice healthy boundaries and self-care during the group process.
• The facilitator may encourage me to seek additional individual, medical, psychiatric, crisis, or other professional support when clinically appropriate
• Group therapy is not an emergency or crisis service.

If I experience an emergency or immediate danger, I understand that I should seek appropriate
emergency assistance rather than waiting for the next group session.

9. Respect for the Therapeutic Process

I understand that each group member may progress differently. I agree not to compare my
healing, insight, participation, or growth to that of another participant.

I understand that there is no guarantee of a particular therapeutic outcome. My progress may
depend on many factors, including my participation, readiness for change, outside
circumstances, and willingness to practice insights and skills outside of group.

I agree to approach the process with honesty, respect, and a willingness to reflect on my
thoughts, emotions, behaviors, values, and patterns.

10. Facilitator’s Right to Protect the Group

I understand that the facilitator has a professional responsibility to maintain a safe and
therapeutically appropriate group environment.

If my behavior significantly disrupts the group, repeatedly violates group agreements,
threatens the emotional or physical safety of others, breaches confidentiality, creates an
inappropriate dual relationship, or otherwise interferes with the therapeutic process, the
facilitator may address the concern with me and determine appropriate next steps.

Possible actions may include:

• Redirecting or limiting certain behaviors during group.
• Discussing the concern privately with me.
• Reviewing the group agreement and expectations.
• Developing a plan to address the concern.
• Recommending additional or alternative services.
• Determining that continued participation in the group is no longer clinically appropriate.

I understand that removal from the group does not automatically eliminate my agreed-upon
financial responsibility for the minimum 8-week commitment, except where otherwise
required by law or agreed upon in writing.

Participant Acknowledgment and Agreement

By signing below, I acknowledge that I have read and understand this Informed Consent and
Group Agreement for the Building From Within: A Self-Worth Process Group.

I have had the opportunity to ask questions and receive clarification regarding the group’s
purpose, expectations, confidentiality, attendance, financial commitment, boundaries, and
rules of participation.

I understand that:

• The group is a 12-week therapeutic group.
• I am making a minimum 8-week financial commitment.
• The cost is $75 per week/session.
• My minimum financial responsibility is $600, even if I miss sessions or discontinue participation before completing the 8-week commitment.
• I agree to respect the confidentiality and privacy of all group members.
• I agree to maintain a respectful, nonjudgmental environment.
• I agree not to engage in hostile arguing, personal attacks, ridicule, or disrespectful behavior toward other members.
• I agree to avoid new dual relationships with group members while the group is active.
• I understand that the facilitator may intervene when group rules or therapeutic boundaries are violated.

I voluntarily agree to participate under these terms.

Participant Name (Printed):	[field id="field_24d84a2"]
Participant Signature:
Date:	[field id="field_428065c"]