Christian Singles Support Group Confidentiality Agreement You have the right to privacy as a member of the Christian Singles

Support Group. Confidentiality within the group setting is a shared responsibility of all members and facilitators. While a group facilitator may not disclose any client communications or information except as provided by law, group members communications are not protected. As such, confidentiality within the group setting is based on mutual trust and respect. Christian Singles Support Group adheres to professional, legal, and ethical guidelines of confidentiality established by professional organizations and state law. Legal and ethical exceptions to confidentiality include: (1) danger and/or risk of imminent harm to yourself or specifically identified others; (2) child abuse (past or ongoing) or vulnerable adult abuse; and (3) responses to court order or subpoena or as otherwise required by law. Please review the following confidentiality agreement: I agree to not disclose any information outside the group that may help identify another group member as being a participant. This includes, but is not limited to, names, physical descriptions, biographical information, and specifics to the content of interactions heard or discussed with other Christian Singles Support Group members. If I am receiving individual support from the facilitator of Christian Singles Support Group, I understand that my confidentiality will be maintained and it is my choice whether to reveal this information to the group. I understand there are no restrictions on those wishing to participate whose divorces may be pending and that ones marital status is agreed to be dealt with in forthrightness and honestly as with any other topic discussed in group.

I agree that any confirmed violation of this confidentiality agreement will result in the offender's forfeiture of participation in the Christian Singles Support Group . Signature______________________________________Date___________________________ Code of Conduct As a member of this group: I agree to be punctual and stay the entire session (unless an emergency arises). The group will start and end on time in order to maintain continuity. I agree that all pagers and cell phones will be turned off during group time. I agree to demonstrate respect for individual opinions and differences amongst group members and will use appropriate language. I understand that I am not required to share, but agree to be a contributor in the group by maintaining a supportive positive attitude whenever possible. I recognize and agree that the role of the Christian Singles Group facilitator may, at times, direct the conversations to allow participation of others, steer conversations towards productive solutions, or intervene for the benefit of the group at her discression. Signature______________________________________Date___________________________ Informed Consent I understand that the facilitator of Christian Singles Support Group, Rosalind Fretz, is a licensed Chaplain with the Internation Police and Fire Chaplains Association and is also a Certified Grief Counselor. I acknowledge that she does not offer psychological, medical, or any type of counseling like unto professions governed by the State Licensing Board. I agree to acknowledge any perceived counsel from the facilitator of Christian Singles

Support Group as intended to be "spiritually supportive" rather than therapeutic in nature. I understand that if my therapeutic needs are greater than group can provide, the facilitator(s) will meet with me outside of group and make referrals to appropriate services. Signature______________________________________Date___________________________ My signature below indicates I have carefully read, signed and understood the Confidentiality Agreement, Code of Conduct, and Informed Consent and willingly agree to abide by all three of the Christian Singles Group terms and conditions . Printed Name: ___________________________________________ Signature: ____________________________________________ Date: ________________