Consent to Treatment
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What is iBE?
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2023-24 Workshop Participant
Informed Consent to Group Treatment
Focus: Relationships throughout life can cause some degree of stress or trauma. This
researched protocol for adults uses the Comprehensive Relationship Protocol--group integrative Bowen and EMDR (iBE) Therapy focused on one of four issues: conflict, distance, triangling, or overfunctioning/underfunctioning reciprocity (codependency). It will assist the participant to clear the distress of past and present memories of interactional conflict, distance, triangling or overfunctioning/underfunctioning reciprocity (codependency) and to learn to replace old patterns with new strategies and skills for healthier attitudes and behaviors.
Note: It is recommended to complete all 4 workshops, at your own pace. Also, it may be necessary to schedule added individual sessions if you believe you have remaining stress or trauma to process after the group workshop is completed.
What do you experience? All participants receive a component of the Comprehensive
Relationship Protocol, depending on which focus they choose. The therapy is offered in a two-day intensive group therapy format. Please see Schedule at ibetherapy.com.
Name of Therapist:
Dana Elken Terrell, LCSW, EAC
This document is to certify that I hereby freely agree to participate in one component of the Comprehensive Relationships Protocol, iBE Group Therapy under the supervision of Dana Elken Terrell, LCSW, EAC.
History: EMDR is a research-validated treatment for trauma. The World Health
Organization lists it as one of two recommended treatments for PTSD, based on the
research. This EMDR-IGTP (EMDR Integrative Group Treatment Protocol) and the
expansion of it, called the Ongoing Traumatic Stress (OTS) protocol has many published
research studies demonstrating its value. Dana Terrell has practiced her method of
integrating Bowen family systems theory for emotional maturity with EMDR-IGTP
therapy since 2015. In the past year she has adapted iBE to include the OTS protocol
because it addresses the truth that we face disturbing relationship patterns throughout
our life, and thus we need a little more opportunity to process experiences on this
theme than her previous approach offered.
The purpose of this group therapy has been fully explained to me and I understand that I will be asked to complete the following:
an Intro Survey to be sure this group experience is appropriate for me at time. If I have no red flags making group treatment inadvisable at this time, I will be invited to join the group I have requested, if there is still space available.
I will answer all surveys/questionnaires frankly to the best of my ability.
I will let the therapist know if I am needing more individual attention.
I understand I may have uncomfortable feelings related to experiences in my past,
present, or my concerns for the future connected to the topic of conflict in relationships.
Previous participants have shared that they were sometimes surprised and even scared
of the intensity of the feelings that came up in EMDR therapy. However, by staying with
the process they could observe that the distress tended to decrease with the EMDR
processing methods. Thus, they began to trust that they could handle intense distress
for 1-2 minutes at a time.
I have been given the opportunity to ask questions, and all such questions and inquiries
have been answered to my satisfaction by Dana Elken Terrell.
I understand that, in the unlikely event of any physical or mental injury resulting from
this investigation, I will not hold Dana Terrell, LCSW and Comprehensive Therapy
Approach, Inc. responsible. I understand that if my distress is above a 5 out of 10 at the
close of a research day, I should inform Dana Terrell, LCSW, who will spend individual
time with me to help me reduce the distress level.
I certify that to the best of my knowledge, I have no physical or mental illness beyond
anxiety or depression, or other weakness that would increase risk during participation in
I UNDERSTAND THAT I AM FREE TO DISCONTINUE MY PARTICIPATION AT ANY TIME.
I understand that if I have any questions concerning the purpose or the procedures
associated with this workshop, at any time along the way I may contact:
Dana Elken Terrell, LCSW at (619) 283-5665 or firstname.lastname@example.org.
I have read all of the above and agree to all of the above terms of participation. I agree that my typed signature on the four signature lines below shall be as valid as a hand-written signature demonstrating my agreement to the terms herein.
I will email this form to email@example.com, or send to 3537 Boundary St., San Diego, CA 92104, or FAX to 619 283-1284.
Update on 2023 Covid and Dana’s Covid Protocol Group Workshops
Please read this updated notice and protocol. Sign below if you agree.
Though people still get Covid, their cases are usually milder than in the past. The danger is less, but still people are getting long Covid and, people are dying. The New York Times on May 11, 2023 reported that in the US, “Covid still takes the lives of thousands every week.”
Of the 12 people Dana knows who got Covid since March, including herself for the first time,2 are still coping with long Covid. Recent research published about long Covid reports that people most prone to long COVID are those who are not fully vaccinated and those who have had repeated cases of Covid. I know one elder woman who fulfilled the first characteristic, but not the second. She needed hospitalization and dealt with long Covid fatigue for some months.
In view of this overall improved picture and the fact that a high percentage of our county is
vaccinated, yet risk continues, she is adjusting the Covid protocol for groups meeting on her patio.
Dana understand that rare individuals cannot be vaccinated due to having strong reactions to vaccinations, and yet feel a need for the iBE protocol. Dana has a friend/healthcare provider who has had dangerous reactions to vaccines. She has not gotten Covid once, but takes many steps to boost her immune system. Also, every hour, she sprays colloidal silver in her nostrils and throat. She’s traveled a lot and has seen clients indoors throughout the pandemic, and remains Covid-free.
Thus, Dana is making the policy more flexible, and has allowed non vaccinated persons to enroll for the group workshop. This is the strategy for accommodatingpeople with differing preferences:
Group wanting more caution:
I will offer one table for those who wish to be masked and distanced from unvaccinated
individuals. Please express your wishes in advance.
Group comfortable with less caution:
I will offer one table six feet away for those who are comfortable without masks. I ask those
who are not vaccinated to share their vaccine status so that the cautious people will be able
to consciously distance as they feel the need. My signature below confirms that if I am not
vaccinated, I will disclose that status at the beginning of the intensive workshop.
Dana has adopted the colloidal silver spray method instead of masking as reliably as she didin the past. However, if anyone requests her to mask while near them, she will. Since it is hard to be heard by all through a mask, while speaking to the whole group, she’ll be distanced and unmasked while guiding the therapy.
We will be sitting in a covered patio with abundant ventilation. While going inside for bathroom breaks, you may wish to wear a mask to protect all. So far, no one has gotten Covid here,and we want that happy result of careful practices to continue.
My signature below indicates I understand and agree to this Covid Protocol:
Thanks for submitting!