As a participant in the Mindful Eating and Stress Management Educational Program, I understand that Dr. Joseph Wieliczko will not be providing treatment or advice for any medical or psychological condition and/or dietary concerns reported during the Mindful Eating and Stress Management Educational Program sessions. These sessions are meant to be educational in nature and anyone who seeks psychological counseling or treatment can be referred by Dr. Joseph Wieliczko to a licensed mental health provider. If I have any adverse reaction (emotional/
psychological) to the suggested practices, I understand that I should discontinue such practices immediately and contact Dr. Wieliczko. I understand that this program is not for the purpose of individual counseling or psychotherapy.
I understand that the purpose of the Mindful Eating and Stress Management Educational Program is to:
- Learn mindful eating practices.
- Learn formal and informal mindfulness strategies as a means to stress management.
Confidentiality: Information you share with Dr. Wieliczko will be kept strictly confidential and will not be disclosed without written consent. Confidentiality still applies for telepsychology services. Confidentiality is not guaranteed in circumstances such as situations where one is of danger to self or others; suspicion or evidence of abuse and or neglect toward children, the elderly, or disabled persons is revealed, or in response to a court order or where otherwise required by law.
- I understand that if this program is conducted by telepsychology services, that there are potential benefits and risks (e.g. limits to client confidentiality) that differ from in-person group sessions.
- I understand that Dr. Wieliczko will not respond to emails or text communications, and that any correspondence would be by telephone, mail or in person only.
- I will be participating in the sessions (if online) while in the state of either Pennsylvania, New Jersey or Delaware. I understand that I am not permitted to record the sessions using any type of technology.
- I, the undersigned, indicate by my signature that I have read the above statements and fully understand, and agree to the above conditions as a participant in the Mindful Eating and Stress Management Educational Program.