From Tween to Teen Girls’ Group

2018 Summer Program

Confidentiality Agreement

Girls’ Group is designed to encourage group members to strive by learning more about
themselves, their peers, and their community, which can be accomplished through honest
discussions on various topics such as the impact of media, healthy relationships, body image, and
self-esteem, etc.

It is important that we all understand the roles that safety and privacy play within these
discussions. While open and honest conversations are encouraged during group, the circumstance
may arise where the leader(s) will need to make the choice to share what was discussed at group
with the group member’s parent/guardian. Disclosure of this kind of information will only occur
if it impacts your safety or the safety of someone else.

Examples of topics that may need to be discussed with parents/ guardians include, but are not
limited to:

• Harm to yourself
• Harm to others
• Serious and risky behavior that could lead or result in harm to yourself and/or others

I, (Group Member’s Name) ____________________________________________, understand

that although From Tween to Teen Girls’ Group is a place where all topics can be discussed
freely, the leader(s) of this specific program may need to report conversations if it is believed
that there is a threat or signs of harm to you and/or others, inside and outside of the group.

Signature of Group member: _______________________________ Date: _________________

Signature of Parent/Guardian: ______________________________ Date: __________________