Parent/Guardian Consent & Pre-Survey

PARENT/GUARDIAN CONSENT FORM
I,
parent/guardian of
, give my consent to Eustress Inc to authorize any routine psychological or therapeutic treatment that is deemed necessary for the well-being of my child as part of participation in the Young Black Male Eustress Initiative. Eustress Inc will inform me and obtain my consent for all recommended therapeutic interventions that extend beyond talk therapy.

I further understand my child's right to privacy. Therefore, I understand to secure and maintain trust between my child and the therapist, none of what my child discloses to the therapist will be shared with me without my child's consent. However, if it is believed my child is at risk of harming himself or another person, it is at that time that I will be informed.

I further understand that I am expected to be involved in the care and treatment of my child during my child's participation in the Young Black Male Eustress Initiative program. This means that I must arrange and participate in regular communication with the assigned therapist.

By signing, I acknowledge full understanding and agreement to all items contained

herein and affirm that I have legal authority as parent, legal guardian or custodian to enter this agreement.
Signature

Clear
Date

MonthDayYear
Date
PARENT/GUARDIAN CONSENT FOR SCHOOL INFORMATION SHARE
I,
parent/guardian of
give consent to (insert child's school)
to share grades (homework, report cards, in-class work, etc.), behavior,incidents, disciplinary actions and other information associated with my son'sschool records with Eustress Inc for the purpose of enhancing the programming andservices they deliver to my son. I understand that this information will be treated asconfidential in conformity with the Family Educational Rights and Privacy Act, willnot be released to other parties and will be used for the sole purposes as describedabove. I understand that participating in sharing this information is voluntary.

I am the parent or legal guardian of the student named above and hereby fully release and discharge the school list above, its officers, employees, and agents from any and all liabilities arising out of or in connectionwith the above described data sharing relative to Eustress Inc. I reserve the right to withdraw my consent at any time with written.
Signature

Clear
Date

MonthDayYear
Date
PARENT/GUARDIAN PRE-ENROLLMENT SURVEY
DATE

MonthDayYear
Date
SON'S NAME
PARENT(S) NAME(S)
STREET ADDRESS
CITY
STATE
ZIP CODE
DAYTIME PHONE
Describe your son's personality:
Has your son engaged in therapy previously?
Share your thoughts about your son engaging in therapeutic activities:
What do you hope your son will gain from participating in this program?
Are there any factors that would prevent your child from participating in this program (i.e., transportation, babysitting, employment or any other responsibilities)?
Is there any other information that you this is important to share with your son's assigned therapist?
Should be Empty:

PARENT/GUARDIAN CONSENT FORM

PARENT/GUARDIAN CONSENT FOR SCHOOL INFORMATION SHARE

PARENT/GUARDIAN PRE-ENROLLMENT SURVEY