A3 Group Participation


1258 High Street, Eugene, OR 97401

Phone 541-342-8437 | Fax 541-242-2999

Participant Name:     Date of Birth:

Pronouns:   

Self-Identified Gender:  

Gender (as specified on insurance):

 

Group Preference: 

 

Consent for A3 Group Participation: LGBTQIA+ Support Group
  • I acknowledge that I will be participating in the LGBTQIA+ support group provided by Center for Family Development (CFD).
  • I understand that I will need to complete an assessment if I wish to later engage in other behavioral health services offered by CFD.
  • I understand that the information shared within the group, including identities of all group members, is confidential. I agree to hold group information confidential.
  • I acknowledge that if information is revealed to CFD of past or threatened abused of a person who is in a protected category, whether that person is myself or another individual, CFD must disclose and report such information, as required by Oregon law. Individuals in the protected category are children, elderly persons, developmentally disabled persons, and persons receiving mental health services covered by OHP or other public funding.
  • Identifying as a member of the LGBTQIA+ community is generally associated with particular stressors with which individuals have to cope. The LGBTQIA+  Support Group is designed to identify these stressors and to provide support and social, emotional, and preventative education.
  • The LGBTQIA+ Support Group includes the following:
    • An affirming stance toward sexual orientation and gender variance.
    • Building a supportive community among participants and reducing a sense of isolation.
    • Recognition and awareness of LGBTQIA+ specific sources of stress (e.g., homophobia, biphobia, transphobia, systemic bias, gender related distress or dysphoria).
    • Recognizing the pervasiveness and consequences of anti-LGBTQIA+ stigma and prejudice and reducing the internalization of negative or stigmatizing thoughts about oneself.
    • Countering negative feelings and low self-esteem that participants may have developed about themselves.
    • Helping LGBTQIA+ youth manage the stresses and stigmatization of marginalization and underrepresentation.
    • Identifying and validating the coping skills and strengths of participants.
    • Learning to transform stressors into challenges.
    • Fostering and supporting a feeling of hopefulness.
    • Embracing an LGBTQIA+ affirming worldview to prevent troubling emotional responses (e.g., shame, anxiety) and subsequent maladaptive behavioral responses.
    • Getting a sense of each participant's risks, in the event that considering a referral for therapy would be appropriate.
  • There may be periods during group that may result in emotional discomfort. The goal and intended benefit of group is education and information about potential stressors, ways to manage them, and transforming stressors into challenges that can be addressed.

I have read and understand this consent and have received a copy. I have had the opportunity to ask questions.

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Signature Certificate
Document name: A3 Group Participation
lock iconUnique Document ID: 6f0ebc86b5d0cf42dfcb2d4bd7e322baf1146802
Timestamp Audit
January 6, 2025 9:19 am PSTA3 Group Participation Uploaded by Do Not Reply - donotreply@c-f-d.org IP 192.111.94.2
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January 7, 2025 8:17 am PSTRecords Email - records@c-f-d.org added by Do Not Reply - donotreply@c-f-d.org as a CC'd Recipient Ip: 150.252.241.10
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