Social Skills Group Registration

Social Skills Group Registration
Program Selection
Participation Requirements This social skills group is designed for children who can participate safely and successfully in a small-group setting. Children must be able to use spoken language well enough to engage in back-and-forth conversation with peers and adults, participate without elopement or behaviors that consistently prevent the group from functioning, independently use the toilet, and manage the personal care and daily living needs required during the group without staff assistance. Registration information will be reviewed to confirm that the group is an appropriate fit for each child.
- Child Information
- Child's name
  
  First NameLast Name
- Child's date of birth
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit year
- Child's age
- Child's school
  Type N/A if not applicable.
- Has your child attended Bloom before?
- Does your child have allergies?
- If yes, list allergies below and let us know how we can accommodate. Please include special instructions and/or medical interventions which may be required.
- Has your child been previously evaluated or received interventions?
- Please describe any current or previous evaluations, diagnoses, and services (such as OT, PT, speech therapy, behavioral support, counseling, or school-based services).
- Which social skills are currently most challenging for your child? Please describe any difficulties with joining peers, back-and-forth conversation, turn-taking, flexibility, reading social cues, or managing disagreements.
- Please describe your child’s strengths, interests, preferred activities, and motivators.
- What do you hope your child will gain from this program?
- Please describe your child’s spoken language skills, including how they express wants, needs, and ideas, understand others, and participate in back-and-forth conversation. Please also describe their ability to focus and sustain attention during activities.
- Please describe any sensory sensitivities, sensory-seeking behaviors, triggers, or regulation strategies that help your child participate successfully.
- How does your child typically participate in a structured small group? Please describe their ability to remain with the group, follow adult directions, transition between activities, and participate without frequently disrupting others.
- Are there any safety concerns we should know about, including elopement, aggression, self-injury, seizures, choking risk, or difficulty following safety directions?
- Does your child need assistance with toileting, eating, dressing, or other self-care during the group?
- Please list any current medications, medical conditions, or other accommodations and supports that may affect participation.
- Parent / Caregiver Information
- Parent / Caregiver name
  
  First NameLast Name
- Parent / Caregiver email
- Parent / Caregiver primary phone
  Format: (000) 000-0000.
- Parent / Caregiver other phone
  Format: (000) 000-0000.
- Home address (no PO boxes)
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Postal / Zip Code
- Please list the best days, times, and method(s) to reach you.
- Please let us know how you were referred.
- Parent / Caregiver #2 name (optional)
  
  First NameLast Name
- Parent / Caregiver #2 email (optional)
- Parent / Caregiver #2 primary phone (optional)
  Format: (000) 000-0000.
- Required Forms
- Financial Responsibility and Attendance Policy
- Cancellation and/or Closure Policy
- Consent for Use of Equipment and Emergency Treatment
  
  In case of an emergency and I am not present, I give permission to the personnel of Bloom Pediatrics, Inc., into whose care my child has been given, the authority to consent to an x-ray examination, anesthetic, medical or surgical treatment and hospital care to be rendered under the supervision and upon the advice of a physician and surgeon licensed under the provisions of the Medical or Dental Practice Act.In the event of a medical emergency and I am not present, I understand that the staff of Bloom will contact 911 or other appropriate medical personnel. If ambulance service must transport my child, I understand that it will be to the closest medical facility able to handle the situation. I understand that my child’s records are protected under state and federal confidentiality regulations and cannot be disclosed without prior written consent. I give my consent to allow the release of information and/or records/reports regarding my child for purposes of emergency medical treatment. I understand the staff of Bloom Pediatrics, Inc. will not be liable for any first aid treatment, medical or hospital care rendered, or drugs, medicine or surgical procedures performed pursuant to this consent.
- Sick Policy, Soiled Clothing, and Head Lice Policy
  
  In consideration for the health of our clients, therapists, and staff, Bloom requires that parents or caregivers do not send their children if they exhibit any of the following: • illness symptoms within the last 24 hours • fever: temperature of 100°F or greater within the last 24 hours • vomiting within the last 24 hours • sore throat or difficulty swallowing • mouth sores, eye discharge, unusual nasal discharge, uncontrolled coughing, difficulty breathing or wheezing, and/or wounds that are not properly covered. I understand that if my child exhibits or develops any of these symptoms during their time at Bloom their activity will be ended and the parent, caregiver, or emergency contact will be immediately contacted to pick them up.
- Please select the ways Bloom may communicate with you about your child’s care. Select all that apply.
- Communication and Correspondence Policy
- Video and Picture Consent
- Social Media and Web Consent
  
  I GIVE CONSENT to have my child’s photographs to be displayed on Bloom's website and social media in order to share my child’s accomplishments and demonstrate their work done at Bloom. I release Bloom, its parent, affiliates, officers, directors, agents and employees, and those acting under its authority, from all debts, claims and liabilities of any kind arising out of or in connection with the use and publication of the photograph/ likeness referred to above. I hereby agree to hold Bloom, its parent, affiliates, officers, directors, agents, and employees, and those acting under its authority, against loss from any claim, action, or demand that may be brought at any time by the above-named minor or by anyone acting on the minor’s behalf for the purpose of enforcing a claim for damages on account of the use and publication of the minor’s likeness and photograph. If I wish to revoke my permission in the future, I will submit my request in writing to Bloom.
- Bloom may send an email newsletter with group activities and photos. It is emailed only to parents and caregivers of children enrolled in the current social skills group and is not shared publicly. Declining or revoking consent will not affect participation or care.
- Newsletter Photo Consent
- HIPAA Notice of Privacy Policies
  
  I attest that I understand and agree to the following: HIPAA NOTICE OF PRIVACY PRACTICES In compliance with the Health Insurance Portability and Accountability Act’s Privacy Rule (HIPAA), your child’s private health information (PHI) will be protected in his/her medical records, in consultation with other professionals involved in your child’s care and with payers, HIPAA requires that your child’s PHI be kept private and that you are notified of the privacy practices with respect to your child’s PHI. A summary of the policies follows. MEDICAL INFORMATION Your child’s PHI may consist of evaluations, diagnosis, daily notes, progress notes, Individual Family Service Plan (IFSP) Individualized Educational Plan (IEP), insurance information, physician prescriptions, and correspondences to your other medical and educational providers (e.g., physician, therapists, service coordinators, psychologists, social worker, school personnel, etc.) COLLECTION, STORAGE, DISCLOSURE AND DISPOSAL OF MEDICAL INFORMATION • Your child’s records will be kept in a file with his/her name on it. These files are stored in a locked container in your therapist’s home office or in a central file at our office. Your child’s records may also be stored in a computer only accessible to your child’s therapist(s). • Correspondence with others regarding your child’s PHI will only include other members or your current child’s healthcare provider team to discuss your child’s course of treatment. • At your request, correspondence with outside consultants or educational personnel will be made. Your written consent is required for this communication to take place. • All phone correspondence with other members of your child’s healthcare team or payer will be conducted on a private phone line in a confidential manner, so others cannot hear the conversation. • All faxed information about your child will include a fax coversheet with a confidentiality statement. No confidential information about your child will be included on the fax cover sheet. • Correspondence by mail will be addressed to specific individuals for the purpose outlined above. • A written record of all disclosures of your child’s PHI will be kept. • Only the Minimum Necessary Requirements will be disclosed to the entity requesting information. This means that only the minimum amount of information necessary to complete the task for which the entity is requesting the information will be provided, rather than sending the entire le. • Your child’s therapist is your child’s Privacy Officer. Each therapist is responsible for protecting your child’s PHI and following these guidelines. • Your child’s records will be kept and stored for a minimum of 6 years. After this time, the records will be shredded to protect privacy. YOUR RIGHTS UNDER HIPAA • You have the right to inspect and copy your child’s personal health information. The request must be made in writing. • Your child’s PHI will be used strictly for evaluation and treatment planning. • You have the right to request information about who PHI has been released to. • You have the right to take away permission to disclose information to any party at any time. This request must be made in writing. • You have the right to complain if you believe your privacy rights have been violated. if you feel your rights have been violated, please contact us. You may also file a complaint with the U.S. Department of Health and Human Services Office of Civil Rights at hhs.gov/ocr/privacy/hipaa/complaints/, 877.696.6775, or U.S. Department of Health and Human Services, Office of Civil Rights, 200 Independence Avenue, SW; Washington, D.C., 20201. We will not retaliate against you for filing. SUMMARY OF RESPONSIBILITIES We are required by law to maintain the privacy and security of your protected health information. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. We will give you a hard copy of this notice and follow the duties and privacy practices described in this notice. We will not use or share your information other than as described here unless you tell us in writing that we can. You may also change your mind at any time and let us know in writing if you do. Additional information is available at hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html TERMS OF CHANGE We can change the terms of this notice. Any changes to this notice will be available to you upon request, on our website, or office. These changes will apply to your information we have on file.
- COVID-19 Release of Liability
  
  I attest that I understand and agree to the following: I am fully aware that there are a number of risks associated with me and/or my child entering Bloom Pediatrics, Inc. property, participating in Bloom programs, and utilizing Bloom equipment and facilities during the COVID-19 pandemic. This waiver, release, and other representations and covenants set forth herein are given in consideration for Bloom Pediatrics, Inc. permitting me and/or my child to participate in Bloom programs during this emergency period. Therefore, without limitation, I understand that I and/or my child could contract COVID-19 disease which could result in a serious medical condition requiring medical treatment in a hospital or could possibly lead to death. On behalf of myself and/or my child and heirs, successors and assigns, I knowingly and freely, assume all such COVID-19 related risks, both known and unknown, relating to me and/or my child’s entry onto Bloom Pediatrics, Inc. property, participation in Bloom programs, and utilization of Bloom equipment and facilities as described above, and I hereby forever release, waive, relinquish, and discharge Bloom Pediatrics, Inc., along with its officers, agents, employees, or other representatives, and their successors and assigns (collectively, “Bloom Representatives”), from any and all COVID-19 related claims, demands, liabilities, rights, damages, expenses, and causes of action of whatever kind or nature, and other losses of any kind, whether known or unknown, foreseen or unforeseen, (collectively, “Damages”) as a result of me and/or my child entering onto Bloom Pediatrics, Inc. property, participating in Bloom programs, and utilizing equipment and facilities as described above, including but not limited to personal injuries, death, disease or property losses, or any other loss, and including but not limited to claims based on the alleged negligence of any Bloom Pediatrics, Inc. Representative or any other person related to COVID-19 sanitization. I further promise not to sue Bloom Pediatrics, Inc. or any Bloom Representative, and agree to indemnify and hold them harmless from any and all Damages resulting from me and/or my child’s contraction of COVID-19.
- Emergency Contact (must be someone other than primary parent/caregiver)
  
  First NameLast Name
- Emergency Contact primary phone
  Format: (000) 000-0000.
- Emergency Contact relationship to child
- Payment Information
- Please select your preferred method of payment below. You will receive an invoice by email. Zelle or check is the preferred form of payment. A 3% processing fee is added to all credit card payments made online. Payment in full is due when invoice is received. Credit card information must be provided for security of payment after registration submission.
- Parent / Caregiver Signature and Date
- By signing below, I attest that I understand and agree to the terms and conditions outlined above.
- Print name
  
  First NameLast Name
- Today's Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
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Social Skills Group Registration

Child Information

Parent / Caregiver Information

Required Forms

Payment Information

Parent / Caregiver Signature and Date