I understand that every attempt will be made to guard my anonymity and confidentiality in this group, but that it cannot be absolutely guaranteed in a group setting.

I realize that confidentiality is sometimes broken accidentally and without malice.

I understand that the group leader is morally and ethically obligated to discuss with me if she observes any of the following behaviors, and this may lead to the breaking and/or perhaps intervention:

  • I communicate anything that may be interpreted as a threat to self-inflicted physical harm.

  • I communicate an intention to harm another person.

  • I reveal ongoing sexual or physical abuse.

  • I exhibit an impaired mental state.

  • I reveal that I am sexually involved with a minor.

  • I reveal that I am involved with the abuse of a minor, elderly person, and/or disabled person.

I have been advised that the consequences for communicating the above types of information may include reports that will be made to the proper authorities – the police, suicide units, and services to children and families, as well as to any potential victims. I further accept that if I am on probation and/or parole and I engage in wrongful behavior in violation of my parole/probation, part of my healing/recovery may include the need to notify the appropriate authorities.

I understand that this is a Christ-centred group, which integrates recovery tools with the Bible and prayer, and that all members may not be of my particular church background. I realize that the Bible may be discussed more (or less) than I would like it to be.

I realize that this is a support group, not a therapy group. I understand that the group leader is qualified by "life experience," and not by professional training as a therapist. The leaders' role in this group is to create a climate where healing may occur, to support my personal work toward recovery, and to share her own experience, strength, and hope.

Name *

Form adapted from “Memo of Understanding,” Pure Desire Ministries Intl. www.puredesire.org. Last revised 3/23/2017.