H.E.A.L K-5 Permission Form

Parents Permission Form

H.E.A.L Together K-5 Group Therapy Program
Email:Outreach@melaninmommiespgh.org
Phone: 412-827-0019
Website: www.melaninmommies.pgh.org
Dear Parents/Guardians,

We are excited to announce the launch of our H.E.A.L. Together ™ K-5 group therapy circles at Urban Pathways K-5 College Charter School. Our group therapy circles are aimed at supporting elementary school students in coping with challenges and promoting emotional well-being. These therapy circles will be led by trained therapists and will provide a safe and supportive space for students to express themselves, build resilience, cope with trauma and grief and learn valuable coping skills.

We believe that participation in these therapy circles can greatly benefit your child, and we invite you to give your consent for them to join. Please read the following information carefully and complete the attached permission slip.

Program Details:

The K-5 H.E.A.L. Together™ group therapy circles will take place weekly on the following dates starting from 09/24/2024 through June 3rd, 2025.

Please see below:

Tuesday: 2nd Grade – 8:30-9:15 am

3rd Grade – 10:10 am –10:55 am

4th Grade -11:00 am-11:45 am

5th Grade -11:50 am- 12:35 pm

Wednesday: Individual sessions as needed.

Monthly: K-1 Group Art therapy Circles (Time TBA)

·        Each therapy circle session will be facilitated by experienced therapists who specialize in working with children and promoting emotional wellness.

·        Students will engage in age-appropriate activities, discussions, and therapeutic exercises designed to help them manage stress, regulate emotions, and develop healthy coping strategies.

·        Confidentiality and privacy will be respected at all times, and students will be encouraged to share only what they feel comfortable with during the sessions.

Benefits of Participation:

·        Improved emotional well-being and resilience-building skills.

·        Enhanced coping strategies for managing stress and challenging emotions.

·        Increased self-awareness and emotional regulation

·        Supportive peer connections and a safe space to express thoughts and feelings
Child's Name

First NameLast Name
Age
School Grade
Date of Birth

MonthDayYear
Date
Parent/Legal Guardian Name*

First NameLast Name
Relationship to the Minor*
Phone Number 1*
Phone Number 2
Email*
Are you also interested in your child participating in individual sessions every Wednesday with one of our licensed therapists? These individual sessions give your child a chance to have one on one time to discuss any barriers to them being a successful student. These sessions are student led and adhere to HIPAA privacy regulations and NASW Code of Ethics. Please type below: "I give consent for individual therapy". If you do not wish for your child to participate in individual sessions, please type below "I do not consent for individual therapy"*
I, {parentlegalGuardian}, the parent or legal guardian of {childsName}, give my permission for {childsName} in grade {schoolGrade} to participate in the K-5 H.E.A.L. Together group therapy circle at Urban Pathways K-5 College Career Charter School. I understand the prupose and format of the therapy circles and authorize my child to attend dessions as scheduled.
Parent's Signature*

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Date Signed*

MonthDayYear
Date
If you have any questions or concerns about the program, please feel free to contact us at Outreach@melaninmommiespgh.org

Thank you for your support in promoting the emotional well-being of our students.

Sincerely,

Latrice Rose-Moore

Executive Director

Melanin Mommies Pgh Inc
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Parents Permission Form