2022 Summer Circles Program Consent

Student's Name*

First NameLast Name

Date of Birth*

Date

Parent or Legal Guardian Name*

First NameLast Name

Cost of Services Policy:

Serenity-BHS has a mental health contract with Cornerstone Academy. This client is a student of Cornerstone Academy and the cost of the program is covered within the scope of the contract with Cornerstone Academy. The client and their parent will not need to pay a fee related to services provided within the Summer Circles Program for Summer 2022.

Do you agree with the Cost of Services Policy?*

YesNo

Informed Consent for Treatment:

I consent to the group therapy program and treatment as outlined in the treatment plan for my child prior to my child attending the program. I understand that this consent is for the duration of the services to be provided. I understand that treatment will involve talking about personal thoughts, feelings, and experiences. I also understand that the focus of the program is to help my child improve their self-esteem, confidence, coping skills and interpersonal relationship skills.

Do you agree with the Consent for Treatment?*

YesNo

Consent to Intern Observation:

Serenity-BHS has Master’s level interns placed with us whom are completing their internship in order to become a licensed therapist. I understand that Summer Circle’s program may include interns and they may work with my child during the sessions that my child attends.

Do you agree with the Consent to Intern Observation?*

YesNo

Communication Policy:

I consent to communications between myself and the Summer Circles therapists through the use of phone calls, emails and/or cell phone texting in order to communicate about attendance or the need to meet related to my child and their participation within the program. I understand that I should only communicate non-confidential information via email and texting with my therapists and that email and texting is not a form of treatment.

Do you agree with the Communication Policy?*

YesNo

Confidentiality Policy:

I understand that my therapist and the staff of Serenity-BHS are committed to maintaining confidentiality. Please note that confidentiality will not be maintained in the event of the following:

1. Any threat to harm self or others, including murder, suicide, and assault.

2. Any reports of actual or suspected child abuse, endangerment or neglect.

3. Any reports, actual or suspected, of abuse of the elderly or dependent adult.

4. Clinician is court ordered to testify or a subpoena requires the release of such records to an attorney or investigator.

5. Guardian or legal custodial parent requests information.

Do you agree with the Confidentiality Policy?*

YesNo

HIPAA Policy:

Your clinician may discuss cases with professional colleagues, without use of names, as deemed necessary. However, your therapist will always abide by the rules as outlined in our agency’s policies, Ohio State Licensing Board rules, and will be compliant with HIPPA.

Do you agree with the HIPPA Policy?*

YesNo

Confirmation

I agree to these policies for my child to participate in the Summer Circles group therapy program I give consent for Serenity-BHS to bill Cornerstone Academy for the services they provide to my student and/or family. I also give consent to Serenity-BHS to send me a confidential Client Survey to get my feedback about the services my child and/or family receive.

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Parent/Guardian Signature *

Date*

Date

Serenity-BHS Staff will contact you to confirm your registration due to spots being limited.