3910 Harry Hines Blvd., Dallas, TX 75219

Phone: (214) 823-5700

Fax: (214) 826-2441

Caregiver Support Group Application

Step 1: Your Contact Details

First Name

Middle Name

Last Name

Primary Phone

Primary Phone Type

Secondary Phone

Secondary Phone Type

Mailing Address

Mailing Street

Mailing City

County

If not listed and in Texas, choose "Other - Texas." If not in Texas, choose "Out of State."

Mailing State

Mailing Zip Code

Step 2: Tell Us About Yourself

Spouse/Significant Other First Name

Spouse/Significant Other Last Name

Your date of birth (MM/DD/YYYY)

Religious Affiliation

Group Preference (check all that apply; hold the Ctrl key to select more than one options)

Step 3: Your Situation and Your Needs

Have you participated in a support group in the past?

YesNo

Why did you decide to join a support group?

Describe your caregiving situation and main issues surrounding the care recipient.

What would you like to get out of a support group?

What topics would you like to talk about in a support group?

What topics would be too difficult to talk about?

Any additional concerns?

Are you willing to complete an assessment questionnaire?

YesNo

Do you need therapy resources?

YesNo

Step 3: Emergency Contact

Emergency Contact

First Name

Last Name

Phone #

Relationship to you

Same address as above

Street Address

City

State

Zip Code

Please read the following guidelines and indicate if you give consent.· Caregiver Support Groups offer a wonderful and practical way to share your feelings and experiences in caregiving and to learn new approaches and resources that can assist you along the way. We provide these basic guidelines to provide a safe and positive experience for all.

General Guidelines for Caregiver Support Group:

· Confidentiality

· Facilitators and group members will maintain all discussion confidential from group meetings and will keep names and discussion confidential outside of the meetings

§ Because confidentiality is essential, we expect that each person will respect and maintain the confidentiality of the group. What is said in group is not to be repeated or discussed at any other time or place. Do not tape or record the meetings.

· By law: As social workers, The Senior Source support group facilitators also need to inform you that they are mandatory reporters. This means if they suspect there is a concern about the safety of a group member causing harm to themselves, or that a group member may harm others, this includes concerns of abuse, neglect, or exploitation, they are required by law to report it to the appropriate authorities.

· Meeting Guidelines

· Allow each group member an opportunity to speak during every meeting

· Share personal concerns, experiences, and questions but focus on purpose of group

§ Facilitators are available for support outside of group meeting time to provide individual support, resources and referrals

· Behavior and Language consistent whether in person, by zoom, or by phone

· Fully dressed in common area

· Language that does not “attack” another individual in the group

· Meeting and member boundaries

· We will not share your individual information with group members

· It is an individual’s decision whether to pursue contact with other group members outside of group meetings-this includes sharing of cell phone numbers, outside conversations, face to face meetings

· It is important to focus on the collective purpose of the support group and to be aware that crossing boundaries can impact the entire group

· We each share the responsibility of making this group work.

· We try to accept people, just as they are, and avoid making judgements.

· We have the right to speak and the right to remain silent.

· We give supportive attention to the person who is speaking and avoid side conversations.

· We do not discuss group members who are not present.

· We begin and end our meetings on time.

Even though our goal is to support each person, this group may not meet all your needs. We encourage each group member to consider engaging in individual counseling/therapy along with attending this support group so that the spectrum of their needs is being met. “There is no such thing as too much support

It is not common, but we reserve the right to remove an individual member if the person does not follow these basic guidelines and places other members at risk.

Consent:

I have read and I understand the Caregiver Support Group information provided above. I agree to follow all guidelines for participation. I have been provided the opportunity to speak with a staff person about the group and to ask any questions I have.

I agree to these guidelines and give consentI do not agree to these guidelines and do not give consent.

Contact Information