On-Line Supervision Group: Agreement for Participation 

    Introduction
    This agreement must be completed on-line and submitted prior to participating in any on-line group therapy sessions. It may be withdrawn at any time, although this will mean that the individual may no longer participate in group sessions There are three agreements in this document:

    1. Confidentiality
    2. Nature of consultative supervision
    3. Payment for service

    Your completion and submission of this document indicates your agreement with the requirements for group membership.

    Feel free to email me with any questions: [email protected]       
    1.  Confidentiality
    It is critical that confidentiality is maintained within this group. All participants/group members must agree to hold in confidence any names, information, specific locations, case information, agency/program information, and sensitive discussion, as well as any other information that might risk the privacy and confidentiality of any former or current client, or risk the privacy and confidentiality of any other participant/group member.

    I have read the above paragraph and agree to to maintain confidentiality regarding all cases, persons, agencies, discussions, other group members, etc., discussed during on-line group supervision. I understand that my agreement is required in order to participate in the group.
    2. Nature of Consultative Supervision
    I understand and agree that supervision provided by Dr. Phil Rich is of a consultative nature, and that Dr. Rich does not assume any responsibility for the actions and choices made by any group member during the course of his or her practice, nor holds or accepts any clinical, administrative, or oversight responsibilities for the caseload of any group member.  
    3. Payment for Services
    I understand that there is a fee to pay for each group session, and that I am expected to pay for group sessions within 5 days of the group session. Payment must be made by PayPal or by other agreed upon means and at the fee established through email correspondence.

     I have read the above paragraph and understand there is a per session fee to be paid within five days of each session, or a group subscription fee to be paid within 5 days of the start of the subscription, and I agree to these terms.
    Please hit the "Submit" button to submit your Participation Agreement, or email me with any questions.