Registration Intake Form

Welcome

Welcome to the Wildfire Resilience Support Group. This psychotherapy group provides a safe, respectful, and supportive environment for adults affected by the 2025 Los Angeles wildfires. Participation is voluntary, and you may choose how much to share. If you have any questions regarding participation or the information provided below, please reach out to Beatrice Ring at (424) 239-9406 or via email at beatrice@calmuracounselingandwellness.org

Psychological Safety & Trigger Awareness:
• Share only what feels comfortable.
• Emotional reactions are normal.
• You may request a break if overwhelmed.
• Practice grounding and self-care.
• Respect each participant's healing journey.

Group Psychotherapy Informed Consent

Purpose: To reduce trauma-related distress, build coping skills, and foster resilience.

Benefits may include increased support, improved coping, and reduced isolation. Risks may include temporary emotional discomfort.

Participation is voluntary.

Confidentiality: The facilitator will maintain confidentiality except when disclosure is required by California law, including suspected child, elder, or dependent adult abuse; danger to self; danger to others; or court order. While all members agree to maintain confidentiality, confidentiality among members cannot be guaranteed.

Confidentiality Agreement & Group Expectations

I agree not to disclose the identity or personal information of other group members, record sessions, or post about the group on social media.

Expectations:
• Respect others.
• Speak from your own experience.
• Avoid interrupting or giving unsolicited advice.
• Attend free from alcohol or non-prescribed substances.
• Silence phones.

HIPAA Acknowledgment & Rights

I acknowledge receipt of the Notice of Privacy Practices.

Participant Rights:
• Be treated with dignity and respect.
• Ask questions.
• Decline to share.
• Withdraw from the group at any time.

Participant Responsibilities:
• Respect confidentiality.
• Treat others respectfully.
• Inform the facilitator of safety concerns.

Communication Policy & Consent

This group is not a crisis service. If you experience an emergency, call 911 or go to the nearest emergency department.

Routine communication should occur during business hours. Sensitive clinical matters should be discussed during sessions.

Consent and Electronic Signature

By checking the box below and entering my name and today’s date, I confirm that I have read and understood the informed consent above, have had the opportunity to ask questions, and voluntarily consent to participate in the Resilience Support Group.

Additional Information

Please provide the information below to help us better understand and serve our community. Your responses are confidential and will not affect your eligibility to participate. You may write “Prefer not to answer” for any optional question.