ICGMV KIDS REGISTRATION

We offer free transportation to children living in the city of Lawrence based on availability.

To support the overall well-being of our participants, we are updating our program requirements. Starting this year, every child must attend:

• One virtual mental health group per week
• At least one activity group per week

I,hereby consent to participate in group or individual Medical Visits. 

The staff explained to me the activities that occurred during the medical visit and provided me with the pertinent handouts.  I understand that a healthcare staff member or staff member will be available. I understand that my protected health information may be shared with the group by the leader to further my medical treatment. I understand that I will be hearing about the medical care and conditions of others in the group, and I have been assured that my protected health information will continue to remain confidential outside of the group medical visit sessions. I understand that my records are and will continue to be protected under applicable Federal and State Regulations., including but limited to the heath Insurance Portability and Accountability Act of 1996, Title 42 of the Code of Federal Regulations, the Health Information Technology for Economic and Clinical Health Act, and cannot be disclosed without my written consent unless otherwise provided for by law.

I understand that: 

I will be in the group/visit with a medical care provider or/and other patients with similar concerns. 

It is my right to withhold personal information that  I do not wish to share. 

It is my responsibly to respect the privacy of others. I will not share their personal information with anybody else. 

I may speak to a medical care provider alone is I have additional problems to discuss. 

I can withdraw at any time for any reason. 

Not participating will not affect my relationship with my provider or my ability to receive service with Kronos health. 

This consent is a supplement to the general consent for services. 

 

My signature confirms that my child clearly understands the activities that occur during a Group/Individual Medical Visit and that I am willing to participate. 

I understand that telemedicine is the use of electronic information and communication technologies by a health care provider to deliver services to an individual when he/she is located at a different site than the provider; and hereby consent to provide health  care services. to me via telemedicine.

 

I understand that telemedicine is being used for the treatment of my case.
 

I understand that the laws that protect the privacy and the confidentiality of medical information (HIPAA) also apply to telemedicine. I will not discuss the issues outside the forum with anyone, to respect to their privacy. 
 

I understand my insurance carrier will have access to my medical records for quality review/audit. 
 

I understand that i will be responsible for any copayments, coinsurances, and co-deductibles that may apply to me during this telemedicine visit. 
 

I understand that I have the right to withhold or withdraw my consent to the use of telemedicine during my are at any time, without affecting my right to future care or treatment in the office or any future telemedicine visits. 
 

I may revoke my consent orally or in writing at any time by contacting Kronos Health/Integrated Center of Group Medical Visits at  978-655-6652.

I, grant Kronos Health and ICGMV the absolute rights and permission to use, reproduce, copy, exhibit or distribute the videotape, audio tape, photographs, or computer files (referred to hereafter as “Video”) in which I may be included for the sole purpose of promoting the services and programs provided by Kronos Health and ICGMV. 

I hereby release, discharge, and agree to hold harmless Kronos Health and ICGMV from any liability or injury that may occur while performing or appearing in the Video. 

I understand that Kronos Health and ICGMV have no financial commitment or obligation to me as a result of this agreement. I hereby give all clearances, copyright, and otherwise, for the use of my name, likeness, image, voice, appearance, and performance embodied in the Video.  

I understand that it is neither expected nor required that I participate in the Video, and I have the right to halt my participation at any point during filming. 

In the case of a minor, I hereby warrant that I am the legal guardian of the minor named below and have every right to contract for him/her in the above regard. I state further that I have read the above authorization, release, and agreement prior to its execution, and that I am familiar with the contents thereof. 

 I,decline to grant Kronos Health and ICGMV the absolute rights and permission to use, reproduce, copy, exhibit or distribute the videotape, audio tape, photographs, or computer files (referred to hereafter as “Video”) in which I may be included for the sole purpose of promoting the services and programs provided by Kronos Health and ICGMV. 

(Safety Rules) Behavior on the Bus:

Girls sitting in designated Back areas.
Boys sitting in designated Front areas.
Be quiet or SILENCE (low voice/indoors voice, NO loud whistling or screaming.
Respect the Driver and each other (No swearing, NO rude gestures, cruel teasing or put -downs).
NO comments about people's physical appearance will be tolerated!!
NO eating or drinking, No chewing Gum.
NO Snacks or Toys from home.
DO NOT use your cell phones (should be put away).
Remain seated facing forward ALL the time until the bus stops at the ICGMV designated stop.
Keep Head, Hands, Feet and All Objects to yourself and inside the Bus.

Entering the Clinic Rules:

ICGMV is part of Kronos Clinic where sick patients need medical help.

All Participants have to be respectful, quiet and walk behind the Teacher on a line to access the Kids Room.

NO EXCEPTIONS

Group Behavior Rules:

ALL the above & More:

Sit down in a circle to get prepared for a quick talk/ topic of the day.
Be polite/ say ”Thank you”.
DO NOT use your cell phones (should be in the bin).
Come prepared for the group wearing appropriate clothing.
Follow the instructors directions the first time.
Help take care of the plants.
Keep group space tidy/ clean up after myself.
Have a good attitude/ participate in the activities.
Respect myself, and other group kids.
Keep my hands to myself.
Be quiet when others are talking.
PARENTS RESPONSIBILITY:

Review the rules of the kids group with my child(ren). I understand that if I would like to CANCEL or CHANGE van transportation for my child, I am required to reach out to the office/coordinator.
If I choose to provide my own transportation, I will promptly pick up my child(ren) on time at the end time of the group.
I realize that I will notify staff if there should be another to pick up my child(ren) and that person will have proper forms of ID.
Support the group in its effort to maintain proper discipline.
Encourage my/our child to be the best that he/she can be and maintain a positive attitude.
Encourage my child(ren) to tell a staff member when something or someone is bothering them.
I understand that if an incident/ injury occurs and involves my child(ren) all parties will be informed, and required to complete a report.
I understand that if my child is being disruptive during transportation and/or the group session my child(ren) will not be able to attend future groups, as appropriate.

The success of group therapy depends upon a high degree of trust between you, your group facilitator, and fellow group members. This document has been prepared to fully inform you and your parents about what to expect from group therapy and from your group facilitators. 

UNDERSTANDING GROUP THERAPY 

Group therapy is a process of understanding more about yourself and others in a safe environment. In group, you will have the opportunity to explore patterns of thinking and behaving that are similar to how you relate to others in your life. Objectives of group therapy include, but are not limited to: 

• Develop skills to assist you in reaching your goals 

• Feel a sense of support from other group members 

• Understand more about yourself and your family system 

• Identify and explore thoughts, feelings and behaviors that hold you back 

• Learn how to improve relationships with others.

 You are welcome to share as much or as little about yourself while in the group, however, the more open you are the better experience you will have. You are welcome to ask questions at any time. The more deeply you understand the process of therapy, the more effectively you will be able to incorporate positive change into your life. 

YOUR GROUP FACILITATOR(S) AND THE THERAPEUTIC RELATIONSHIP

 The relationship between you and your group facilitator(s) is special and unique. You will be sharing information in group that is sensitive and personal. Your group facilitator’s primary responsibility is to create an atmosphere of safety and support in order for you to get the most out of group. Your group facilitator will encourage each group member to be honest, vulnerable, and respectful about his or her feelings and observations in the group. If you are ever feeling unsafe in group, you are encouraged to discuss this with your group facilitator. If for any reason you experience any negative reactions or blocks towards participation, please share this with the group. Your voice is your power and your right. 

CONFIDENTIALITY

 It is important that you feel comfortable in group to talk freely about whatever is bothering you. Sometimes you might want to discuss things that you do not want your parents or guardians to know about. You have the expectation of privacy in group sessions. As a general rule, group facilitators do not talk to your parents about what you discuss in group without your permission. However, there are some exceptions to this rule. In some situations, in accordance with professional ethics and state laws, your facilitator may disclose information without your permission. Some of the circumstances where disclosure is required by law are: 

• If you, another minor, a dependent person, or an elder adult is being abused 

• If you are in danger of hurting yourself, someone else, or another person’s property 

• When a family member communicates to your facilitator that you present a danger to others If you are doing things that could cause serious harm to you or someone else, your facilitator will use their professional judgment to decide whether a parent or guardian should be informed. In these situations, your facilitator will talk with you about their concerns and discuss the best way to include your family in order to get the support that you need.

GROUP MEMBER’S AGREEMENT FOR CONFIDENTIALITY 

All members of the group will be asked to agree to a high level of confidentiality in the group sessions. This means that each participant agrees not to share any other group member’s identifying and personal information with others. It is appropriate to share your personal reaction and feelings about the group with others, but please do not share other people’s stories with anyone outside of the group.

In the case of an emergency authorized you to contact and/or release my child to the person listed above. 

Alternative Pick-up Person(s):

I hereby inform Integrated Center for Group medical Visits that the person(s) listed below are authorized to pick up my child , and I instruct the integrated Center for Group medical Visits  to release my child into the care of such authorized person(s) when they come to the Integrated Center for Group medical Visits.