Dr. Sheri’s In-Person Empowerment Group Agreement

Please review and fill out the form.

Thank you so much for taking the time to apply to my In-Person Empowerment Group. I can’t wait to connect with you. Please review the following information carefully. I want you to be familiar with policies/procedures so that things can run smoothly. Please take your time and make sure you’re carful as you read so that there are no misunderstandings later on. If you have any questions please send an email to info@drsherikeffer.com. My team & I will be happy to assist you.

Warmly,
Dr. Sheri

PROCEDURE/CONFIDENTIALITY:

The In-Person Empowerment Group is a valuable, private, and confidential group. I agree to treat each meeting with the upmost respect and care. I understand that I may not bring anyone with me to the sessions. I will not eat during the group. I will be on time. I will come prepared with questions about the Empowerment Wheel and challenges I may be experiencing.

I understand that group members names and any comments or discussions that occur within the group are strictly confidential. By typing my name below I agree to maintain confidentially of all members of the group.

I understand that Dr. Sheri is a mandated reporter; thus, required to report to the proper authorities any of the following:

1. Any reasonable suspicion of physical or sexual abuse of a child, minor, elder, or an adult with a disability.
2. When a participant communicates a threat of bodily injury to others.
3. When a participant may be a threat to herself/himself or has plans of suicide.

PROTECTING GROUP CONNECTION & NO SIDE CONVERSATIONS:

I understand that protecting my group connection & guarding against side conversations while my group is in their healing process maximizes the benefits of the group while protecting the safety of each participant from unhealthy alliances or gossip. I understand that it’s very common when participating in a group, that relational dynamics of family of origin, unhealed wounds come to the surface, let me know, often via felt pain, that something needs attention & healing. I understand I might feel triggered by someone or I might trigger someone else. I might feel irritated by certain personalities or temperaments as they might remind me of someone that has hurt my heart. When safe, a group is done, an invitation for deeper relational healing within the group context can take place. To that end, in order to best support group dynamics, growth, pain and opportunity to heal, I understand that the In-Person Empowerment Group does not allow side conversations between members of the group to happen outside of the face-to-face group sessions or any other way.

I acknowledge that I may have come into the In-Person Empowerment Group session with an already established friendship with one of my other group members. Or that I might develop a friendship with a member of my group during the In-Person Empowerment Group session. So, I agree to the following:

1. I agree that I won’t discuss any information about someone else in In-Person Empowerment Group outside of my group sessions.
2. I agree that I won’t discuss any personal & confidential information that was discussed in the In-Person Empowerment Group sessions.
3. I understand that I’m free to share my story.
4. I also understand that me sharing my story does not include my reaction, feelings or experiences with or about In-Person Empowerment Group or another member in the group.
5. I agree that if I do have a reaction, feeling or experience that I want to discuss about In-Person Empowerment Group or a group member, that I will ONLY discuss it within my group session and NOT with a friend or friends that I’m in In-Person Empowerment Group with.
6. If I violate these terms and discuss information about my group or a group member with my friend, I’ll be required to bring that conversation back to the group.
7. I agree to place the safety and protection of In-Person Empowerment Group and its members at the highest level.
8. I understand that this applies during the 12-week session.

I agree not to contact my group members outside of In-Person Empowerment Group sessions during the 12-weeks. I understand that doing so is a violation of this agreement.

MEETINGS:

There will be 12 meetings, each meeting will last 90 minutes. I agree that if I am sick or going to miss a meeting, I will let Dr. Sheri know. I understand that there will be no makeup meetings and that I’m obligated to pay for all 12 sessions regardless of whether or not I attend.

DECISIONS:

I understand that I am responsible for the decisions I make about my work with the In-Person Empowerment Group. Dr. Sheri is happy to share opinions, offer resources, or make referrals. However, it is up to me to decide which, if any, to act upon.

I understand that if I decide to take a recommendation Dr. Sheri gives, it is my choice and I take full responsibility for it. If I decide to work with someone based on a referral, I understand that the workings of that relationship will be entirely separate from my relationship with the In-Person Empowerment Group & Dr. Sheri.

I understand that I may stop attending the In-Person Empowerment Group at any time. If I choose to do so, I understand that my fees will not be refunded.

MY COMMENTS:

At the end of the 12 weeks in the EIn-Person Empowerment Group, I understand that I will be asked to write a few comments about my time in the EIn-Person Empowerment Group as an evaluation. I understand that it helps Dr. Sheri to see what I liked about the process, what results I received overall, and anything else I would like to add. I understand that Dr. Sheri may use my comments in the form of a client testimonial to share with others who are thinking of participating in an In-Person Empowerment Group. I understand that it is my responsibility to let Dr. Sheri know if I do NOT want my comments used from the closing evaluation. This DOES NOT include any and all comments made during the In-Person Empowerment Group. Those will ALWAYS remain confidential and will never be shared.

PROBLEMS:

I understand that Dr. Sheri wants me to be satisfied with my In-Person Empowerment Group experience. I agree that if Dr. Sheri ever says or does something that upsets me or doesn’t feel right, I will bring it up either to Dr. Sheri. All comments can be emailed to info@drsherikeffer.com.

DIVERSITY:

I understand that the In-Person Empowerment Group is open to all participants regardless of their faith orientation. Some elements of the teaching draw from references to God and from a Christian-based philosophy, which may influence the teaching/group support I receive in the In-Person Empowerment Group.

I understand that participants in the In-Person Empowerment Group come from all ranges of trauma experiences, varied beliefs, lifestyles, orientations, socioeconomic, age, and spiritual faith experiences. Healing comes as we curiously enter into understanding a person’s experience from a non-judgmental stance. It is requested that we refrain from trying to fix another person or impose beliefs that we deem may be best for that individual. The devastation that comes by way of existential trauma, relational trauma, socioeconomic trauma, spiritual/faith trauma has the ability to be processed and worked through within an environment of safety.

PERSONAL RESPONSIBILITY:

I understand that I am responsible for my own results in connection with the In-Person Empowerment Group experience. I understand that if I choose not to implement things I’ve learned in the In-Person Empowerment Group, I may not see the progress I’m hoping for.

I understand the maximum benefit will occur with consistent attendance and at times I may feel conflicted about my In-Person Empowerment Group experience as the process can sometimes be uncomfortable. Continuing through the In-Person Empowerment Group can lead to personal insight and growth.

I understand that the group is impacted by my presence and am committing to attend all 12 In-Person Empowerment Group sessions.

If I have been advised by my physician or psychiatrist to use medication of any kind, I agree to continue using my medications as prescribed during the course of this In-Person Empowerment Group.

I further understand and acknowledge that the In-Person Empowerment Group is not psychiatric treatment, and that no doctor-patient or therapist-client relationship is established by my participation in this In-Person Empowerment Group.

I agree to cooperate fully with Dr. Sheri and her staff, and I understand that failure to do so may result in removal from the In-Person Empowerment Group.

RELEASE OF INFORMATION:

I authorize Dr. Sheri and her staff to release and disclose information to other staff members regarding billing or financial issues.

INSURANCE REIMBURSEMENT:

I understand that Dr. Sheri will provide me with a monthly superbill to submit to my insurance company. She does not bill out to insurance companies and is considered an out-of-network provider. The first copy of a superbill will be provided free of charge. I understand that if I request a second copy of a superbill that I will be charged for it. I understand that I may not be reimbursed by my insurance company and agree to take on the responsibility of payment for services rendered regardless.

FEES:

I understand that I am responsible for the total cost of the In-Person Empowerment Group experience. I agree to notify Dr. Sheri and her staff if my payment information needs to be updated or adjusted in any way. In the event any method of payment of fees and/or expenses proves nonredeemable or non-transferable by a U.S. bank or financial institution, I agree to pay an insufficient funds fee of $35. I understand that I am responsible to pay for all In-Person Empowerment Group sessions in advance regardless of my attendance. I understand that In-Person Empowerment Group fees are non-refundable.

COPYRIGHT OF MATERIALS:

I understand that materials provided to me during the In-Person Empowerment Group are copyrighted. Under no circumstances can the copy in these documents be used or reproduced in whole or part without the express written permission of Dr. Sheri Denham Keffer. The absence of a copyright notice on any given page or material should NOT be construed as an absence of copyright. These copyrights have been successfully defended in the past, and it is the policy of the Dr. Sheri Denham Keffer and Lionheart Marriage and Family Counseling PC to aggressively defend all intellectual properties.

STATEMENT OF UNDERSTANDING:

I understand that any fees are non-refundable and that the In-Person Empowerment Group sessions will not be rescheduled if I cannot attend.

RELEASE OF LIABILITY:

By typing my name below, I agree that I am a voluntary participant in the In-Person Empowerment Group. I agree to release and discharge as well as agree to indemnify and hold harmless Dr. Sheri Denham Keffer, Lionheart Marriage and Family Counseling PC, BraveOne Community Inc, Karene Dodson/Integral Solutions, all of Dr. Sheri’s staff, their officers, directors, employees, agents and subcontractors, against all actions, causes of actions, claims, demands, costs and expenses and liabilities of any nature whatsoever that I may suffer directly or indirectly during the course of or as a result of my participation in the In-Person Empowerment Group.

On this date, I entered into a relationship with BraveOne Community Inc and/or Lionheart Marriage and Family Counseling PC, Inc., Dr. Sheri Denham Keffer, and her staff. I have read and agree to the policies and procedures above. A copy of this document will be emailed to me at the address provided.

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