Kid Talk Flipbook For Review 05.10

Support Group Agreement (Sample)
Support Group Agreement
For “Kid Talk” Bereavement Support Group
The “Kid Talk” series in which ____________________________ is enrolled, will meet for fourteen (14)
sessions at the following times & location:
Day:
Time:
Location:
Facilitators:
________________________________________________
________________________________________________
___________________________________________________________
________________________________ and ____________________________________
I, __________________________________________________, understand that:
(Please print first and last name.)
1. The purpose of the group is to help my child work through the normal grief process.
2. What and how much he/she shares is up to him/her. He/she always has the right to pass.
3. Every reasonable effort will be made to maintain confidentiality about all aspects of his/her
participation in the group; however, confidentiality cannot be guaranteed due to the
participatory nature of a support group. If he/she chooses to disclose information that indicates
a danger of harm to him/herself or others, then the facilitator will be obliged to report it.
4. Homework, referred to as “take-home griefwork,” may be assigned. These exercises have been
found to help other persons work through their grief. I will encourage my child to complete these
assignments.
5. Kid Talk facilitators are not therapists and do not offer psychological counseling or therapy but
offer education and support on the topic of grief. If the Kid Talk leaders think that your child has
complicated grief which requires therapeutic intervention, the parent/guardian will be given a
referral to a mental health professional.
6. If my child is in counseling or therapy, it is my responsibility to notify the counselor of his/her
participation in Kid Talk.
7. If unable to attend a session, I will notify a facilitator or someone in the group before the meeting.
8. I may call any time with questions or concerns at:
____________________________________________________________________________,
__________________________________________
Signature of Parent or Guardian
_____________________.
Date
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