Family Safety Network Support Group Confidentiality Agreement

Name: _____________________________________________
Address: ____________________________________________
Address: ____________________________________________
Phone: _____________________________________________
E-mail: _____________________________________________
Date of Birth:________________________________________
During my membership in the Support Group I may learn personal and confidential information about
individuals who participate or are involved with this Group.
Whether information is available to me through the Group or accidentally, I agree to maintain
confidentiality and not reveal information that is not existing public information to any person in the
Group or outside of the Group while a Member of the Group or at any time in the future when I may no
longer be a Member of the Group.
I understand that breaking of this agreement could result in the termination of my membership with
the Support Group.
I understand that any information pertaining to my health should be reviewed with my physician.
Nothing provided herein should be construed as a substitute for professional advice or treatment by a
health care professional. The group facilitator is a mandated reported, will report any reports of selfinjurious
plans or plans to harm other, child abuse, or vulnerable adult abuse.
Although good faith efforts have been taken to preserve participant confidentiality, no guarantees
can be made in this regard nor to information communicated by and between participants in this
Signature of Member: ______________________________________ Date: ______________________
Signature of Witness: _______________________________________ Date: _____________________

Peer Group Participation Rules

1. What is said here stays here. Don’t break group member confidentiality and/or those we serve (no
identities revealed—use as little identifying information as possible while talking).
2. Listen. Listen. Listen.
3. Be open to feedback.
4. Earn the right to give feedback by listening before talking.
5. Ask permission to give feedback.
6. Avoid giving advice and “fix-it mode”
7. Speak “I” language (speak for yourself).
8. Respect the talker—no cross talk.
9. Be Mindful of your Body Language (sighing, rolling eyes, facial gestures, arms crossed, etc.). Be
“open”, not “closed”.
10. Remember, it’s okay to compromise. It’s okay to agree to disagree
11. Avoid mind reading. When in doubt, check it out.
12. Only talk about group members that are present
13. Stay focused on topic
14. Respect the group by showing up, regularly and on time.