Support Group Registration Form

Divorce Support and Recovery - Starting Sept 10th, 2010

About you



Contact Info
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Other Info

Payment Plan

Registration Fee and Materials: $35.00
Cheques are payable to Calvary Assembly (Emmaus)

Commitment

In the event that we may need to reach you, information on this contact sheet may be shared with Divorce Group facilitators, Emmaus Counselling Centre, and church staff if determined necessary.

 

I have read the Directives and Guidelines and understand what I may expect from the Divorce Support & Recovery Group offered by Emmaus Counselling Centre. 

 

I consent to enter the group with this understanding.  By clicking below  I indicate my agreement with the Guidelines and Directives outlined on the previous pages. You will also need to sign a form when you arrive in person.


 

INFORMATION

1. This is a 12 week program that meets weekly. If you are unable to commit to the 12 weeks you have the option to purchase the material only without attending meetings. Admittance into the meetings will be closed after the third session.

2. This program is not intended to provide an opportunity to look for new dating or marital relationships.

3. This program is open to any separated or divorced person regardless of faith, gender, or parentage. This group will be diverse.

4. This program is not intended to deal with children’s issues. It is adult oriented.

 LIMITATIONS

Facilitators will not counsel, attend court hearings, be a personal witness, or meet outside of meetings.

Anyone attending while under the influence of drugs (illegal or prescription) or alcohol will be asked to leave that session.

Use of cameras and/or recording devices will not be permitted.
 

The use of profanity is not acceptable.
  

Information regarding the content of the meetings is strictly confidential except as noted on the registration form.
 

We strongly discourage discussing the content of the meetings outside the meetings unless it is information regarding yourself or the person you are talking to.

All information shared within the group is confidential and subject to rules regarding privileged conversation among group members.  Facilitators reserve the right to discuss pertinent information with their supervisors. 

 

By law your facilitator may be required to release information to other appropriate sources in four specific situations:

1. There is reasonable belief that you will harm yourself.

2. There is reasonable belief that you will do harm to others.

3. There is reasonable evidence of neglect, physical and/or sexual abuse to a minor.

4. There is reasonable belief that a regulated health professional is guilty of professional misconduct. 


 

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