GROUP CLINICAL CONSULTATION

Enrollment

Name

Email Address (associated with your Zoom account)

What do you hope to get out of a peer consultation group?

What type of professional license do you hold and in what state? Please include active license number and link to your Board license lookup.

Agreement

Please check the boxes below to confirm your agreement with group requirements:

1. While consultation will occur on a HIPAA compliant, secure platform, you understand that it is your responsibility to abide by your professional code of ethics regarding disclosing client information and protecting privacy.

2. You understand that all information shared during consultation, whether about a client or a provider, is to be held in confidence and not discussed outside of consultation.

3. You understand that this is a consultation space for independently licensed mental health clinicians and is not currently open to anyone unlicensed or under supervision.

4. You are aware that this is a collaborative group that provides peer support and is not a space for personal therapeutic processing. You understand that consultation is distinctly separate from psychotherapy and all members are advised to seek their own therapist for support as is necessary to support their own mental health.

5. You agree that should something change about your current clinical status (complaint against your license, disciplinary action with employer, claim filed against liability insurance, criminal charge reportable to Board, etc), you will inform me directly in order to determine your eligibility to continue in the consultation group.

Thank you for enrolling in our clinical consultation group. You will be added to the zoom group once your license has been verified. If you need to contact me before our next consultation group, you can reach me at info@meaganfaraonelcsw.com.