Parent/Guardian Consent Form For Group Counseling/Case MGMT Services

The group will be held at the above-listed school, from the date of signature to discharge.

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.