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Group Consent Form
Parent/Guardian Consent Form for PsyCare Summer Program
Child's Name:
*
Child's Name:
First
First
Last
Last
Parent/Guardian Name:
*
Parent/Guardian Name:
First
First
Last
Last
Parent/Guardian Phone Number:
*
*
By checking this box, I affirm that I permit my child to particiapte 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 on the following days and times at the following location:
*
East Liverpool: Tuesday-Thursday from 8:00 A.M. to 12:00 P.M. from June 20th to August 10th
Struthers: Tuesday-Thursday from 10:00 A.M. to 1:00 P.M. from June 12th to July 21st
Campbell Session 1: Monday-Thursday from 8:00 A.M. to 1:00 P.M. from June 5th to June 30th
Campbell Session 2: Monday-Thursday from 8:00 A.M. to 1:00 P.M. from July 17th to August 11th
Salem: Tuesday, Wednesday, and Thursday from 11:30 A.M. to 2:30 P.M. from June 6th to June 29th.
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:
*
We are able to provide a hot lunch to your child for the first two weeks of the program. From June 26th through July 21st, we will not be able to provide a hot lunch due to facility restrictions. Please check the box below to confirm you will be able to provide a packed lunch to your child after the first two weeks of the program. If you are unable to provide a packed lunch, please indicate below, and we will ensure we have snacks provided.
I will be able to provide a packed lunch to my child from June 26th to July 21st.
*
Yes
No
May we serve snacks to your child in the event you are unable to provide a packed lunch?
*
Yes
No
May we serve lunch to your child?
*
Yes
No
Are you planning on sending lunch with 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. By signing this consent form, I understand that Group Intervention will be added to my child’s Treatment Plan and participation documented in his or her Electronic Medical Record (EMR). 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 informed consent for my child to participate in Group Counseling and/or Group Case Mgmt. Services for the time period documented on this form.
Parent/Guardian Signature:
*
Clear
Today's Date:
*
Submit