Exploring Embryo Donation Series
pARTICIPANT cONSENT
EM•POWER with Moxi Donor Support Group Participant Consent Form
Name and Aliation of Group Facilitator
Jennifer Vesbit
EM•POWER with Moxi, Donor Specialist (503) 837-1810 jen@empowerwithmoxi.com www.empowerwithmoxi.com
Information About the Support Group
You are invited to participate in a facilitated group to provide support and education to embryo donors who are in the pre- and post-donation phases of embryo donation. The group will meet through video chat for 90 minutes on Tuesday evenings at 5:30-7:00pm PST for five weeks from the dates of February 28, 2023 to March 28, 2023. The group does not take the place of individual therapy and is not considered psychotherapy. The group welcomes individuals at dierent stages on their embryo donation journey.
Feedback Survey
At the end of the five week session, all participants will be asked to complete a short feedback survey to help the the team at EM•POWER identify potential areas of improvement for the support group model.
Participation
Participation in the support group and in the feedback survey is completely voluntary. If you start the group, you may quit at any time. However, the fee is non-refundable.
The group is intended as a safe space for all members to share, learn and be heard. The participant agrees to communicate honestly, be open to feedback and assistance and to create the time and energy to participate fully in the meetings.
Confidentiality
Discussion group confidentiality: Participant agrees to not share other participants’ personal stories or private information outside of the group.
Although the facilitator will take every precaution to maintain the confidentiality of what is discussed, the nature of a group setting prevents the facilitator from guaranteeing confidentiality. The facilitator may share anonymous, aggregated insights from the support group with other members of the EM•POWER project team if they are necessary or helpful to support participants or the group process.
Survey data confidentiality: All data from the closing feedback survey will be kept confidential. Individual participants will not be identified in any summaries or write ups of the survey responses.
Late/Cancellation Policy
The group will begin promptly at the designated time. Please notify the group facilitator 24 hours in advance of the scheduled meeting if you cannot attend.
Contacts
If you have questions about the project or your participation in the support group, please contact Jennifer Vesbit at Jen@empowerwithmoxi.com.
------------------------------------------------------------------- EM•POWER with Moxi Recipient Support Group Participant Consent Form
Name and Aliation of Group Facilitator
Maya Grobel
EM•POWER with Moxi, Recipient Specialist (503) 837-1810 Maya@empowerwithmoxi.com www.empowerwithmoxi.com
Information About the Support Group
You are invited to participate in a facilitated group to provide support and education to anyone exploring embryo donation or currently in an embryo donation journey as a recipient. The group will meet through zoom for 90 minutes on Wednesday evenings from 5:30-7pm PST for five weeks from the dates of February 1, 2023-March 28, 2023. The group does not take the place of individual therapy and is not considered psychotherapy. The group welcomes individuals at dierent stages on their embryo donation journey.
Feedback Survey
At the end of the five week session, all participants will be asked to complete a short feedback survey to help the the team at EM•POWER identify potential areas of improvement for the support group model.
Participation
Participation in the support group and in the feedback survey is completely voluntary. If you start the group, you may quit at any time. However, the fee is non-refundable.
The group is intended as a safe space for all members to share, learn and be heard. The participant agrees to communicate honestly, be open to feedback and assistance and to create the time and energy to participate fully in the meetings.
Confidentiality
Discussion group confidentiality: Participant agrees to not share other participants’ personal stories or private information outside of the group.
Although the facilitator will take every precaution to maintain the confidentiality of what is discussed, the nature of a group setting prevents the facilitator from guaranteeing confidentiality. The facilitator may share anonymous, aggregated insights from the support group with other members of the EM•POWER project team if they are necessary or helpful to support participants or the group process.
Survey data confidentiality: All data from the closing feedback survey will be kept confidential. Individual participants will not be identified in any summaries or write ups of the survey responses.
Late/Cancellation Policy
The group will begin promptly at the designated time. Please notify the group facilitator 24 hours in advance of the scheduled meeting if you cannot attend.
Contacts
If you have questions, please contact Maya Grobel at Maya@empowerwithmoxi.com. Please check this box to acknowledge that you agree to the above terms.