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Group Consent Form
Group Consent Form
Parent/Guardian Consent Form for PsyCare Summer Program
Child's First and Last Name:
*
Parent/Guardian First and Last Name:
*
Parent/Guardian Phone Number:
*
*
By checking this box, I affirm that I permit my child to participate in group activities led by PsyCare mental health staff.
By checking the relevant box below, I affirm that my child will participate in group activities led by PsyCare mental health staff at the following location:
*
East Liverpool City Schools
Struthers City Schools
Campbell City Schools
Salem City Schools
Is your emergency contact different from parent/guardian listed above?
*
Yes
No
Emergency Contact Name:
*
Emergency Contact Name:
First
First
Last
Last
Emergency Contact Phone Number:
*
Based on school staff availability, we may able to provide a hot lunch to your child throughout the duration of this program. We will notify you if hot lunch is not available. Please check the box below to confirm you will be able to provide a packed lunch to your child if we have notified you that we are unable to provide lunch. If you are unable to provide a packed lunch, please indicate below, and we will ensure we have snacks provided.
May we serve a hot meals (breakfast and or lunch) to your child if available?
*
Yes
No
I will be able to provide a packed lunch for my child when hot lunch is not available.
*
Yes
No
*
Please check this box to confirm that you will be able to provide a packed lunch for your child.
May we serve snacks to your child?
*
Yes
No
Does your child have any food allergies or dietary restrictions?
*
Yes
No
Please list any food allergies:
*
Please list any other food or dietary restrictions:
I understand that:
1. Group Leaders will provide an opportunity for students to learn and practice interpersonal social skills, coping skills, discuss feelings, share ideas, and practice new behaviors. 2. Information shared by students in group will be kept confidential by the Group Leader, in accordance with HIPAA and Ohio law if Medicaid or insurance is being billed. 3. There will be other children in the group; therefore, confidentiality cannot be guaranteed. All children will be advised that what happens in group stays within the group. 4. Group Intervention will be added to my child’s Treatment Plan and participation documented in their Electronic Medical Record (EMR). 5. If any changes or alterations need to be made to this form, it is my responsibility to notify a PsyCare staff member. We will try to maintain your child’s confidentiality when possible in accordance with the laws that apply. If concerns arise during group conversations, we will assist you in resolving the situation in an appropriate manner. My signature indicates that I am giving written informed consent for my child to participate in Group Counseling and/or Group Case Mgmt. Services for the duration of their treatment unless revoked by a parent/guardian.
Parent/Guardian Signature:
*
Date:
*
Submit