Adalyn Rose Foundation Support Group, facilitated by Our Whole Living Counseling: Informed Consent

First & Last Name:

Email address

Phone Number

BY CLICKING THIS BOX YOU CONSENT TO THE FOLLOWING: This support group is for mothers and fathers to have a place to talk honestly and openly about your pregnancy loss and/or infant loss. This is a place where you can be honest with yourself and others, and may give and receive support. You do not have to be diagnosed with any specific illness to be here. Some group members may be in treatment for a particular diagnosis, some may not. Anyone who wants to talk about their loss experience is welcome. This is not a therapy group. This is not a substitute for psychiatric care or psychotherapy or medical treatment. The goal is to provide a safe place for you to talk about your thoughts and feelings related to loss. The best thing you can bring to the group is a willingness to listen to others. We do not try to solve every problem, and you do not need to give advice or solutions to others. The facilitator is here to answer questions, to guide the discussion, and provide resources when needed. The facilitator may be a licensed therapist, a therapist-in- training, or a peer support leader. This virtual group is held via Zoom. You will receive a link for the meeting once. That link will be the same link for every meeting. If you need a new link to the meeting, please email: owl@ourwholeliving.com. Here are the ground rules for the group: Keep everything shared here confidential. We want it to be a safe, secure place for all to talk. Give everyone who wants to share a chance to talk. Do not force anyone to share more than they want to. Don’t give advice or tell others what they should do. If you want to share a thought with somebody about their story, ask if they want feedback or input before giving it. If you are experiencing symptoms that appear to need to be addressed by a healthcare professional, the facilitator may encourage you to do so, as well as help you identify resources. We provide a list of some of the providers who have identified themselves as qualified to address issues related to loss. If you are a danger to yourself or others, we must assist you in finding an appropriate level of care. We will assist you in contacting the necessary organizations which will assist you and your family safe from harm. I have read and understand the above information, and agree to the group rules for the support group.

Emergency Contact Name & Phone Number

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