Experiential Support Group for SWK

Informed Consent Form:

Experiential Support Group for SWK 601

As part of SWK 601, I agree to participate in a 6-10 session Experiential Support Group comprised of class members. Each group will be approximate 40-50 minutes in length and will meet each week. The group will be facilitated by class instructor. I understand that the purpose of the group is to enhance my affective, cognitive and experiential knowledge of group work in social work practice. I understand that information in the group is to remain confidential and that any person who violates the confidentiality of the group will receive a failing grade in the course.

The course instructor, Dr. Rachel Robinson, has discussed the risks and benefits to this group experience with me. Potential benefits of participation as a group member and a group observer include increased knowledge and skills relate to social work practice with groups and increased social support. A potential risk related to participation is that personal information revealed in group could be disclosed to others outside the group, resulting in emotional hurt and/or professional repercussions. Another risk of group participation is that if I violate the confidentiality rules of the group, I may be expelled from the group and I may receive a failing grade for the course.

I understand that Dr. Rachel Robinson will not disclose any information I choose to share in group outside of group with the following exceptions required by law and/or social work ethical guidelines:

If I express knowledge of abuse or neglect of a child or vulnerable adult; and

If I express intent to harm myself or to harm other people.

Dr. Rachel Robinson has informed me that there will be guidelines for group (decided upon by the group) that will include the importance of keeping information discussed in group confidential. I have also been informed that I receive a grade for this activity based on my attendance related to the groups and journal entries that I write as a result of the groups. I have been informed I will not be graded on the issues I discuss in group or on the growth I experience or do not experience as a result of the Support Group. I have been informed that I am able to choose what I share or do not share in group.

I have read and fully understand the information provided about the benefits and risks of participation in this group. I have discussed the benefits and risks with the class instructor and I have had the chance to ask all the questions that I wished to ask about the matters listed above and about all other matters. The class instructor has answered my questions in a way that satisfies me. By signing this document, I agree to accept the risks listed in this form and the risks explained to me by the class instructor in the hopes of achieving the benefits discussed.

Signature of Group Member/Student Date

Signature of Class Instructor Date

Signature of Witness Date