Support Group & Workshop Consent Packet

Group and Workshop Consent
All group and workshops will be paid in advance to reserve your spot in the group or workshop, and are non-refundable. A receipt will be provided.
The TOTAL fee for the group or workshop is*
Client initials*
CLIENTS 14- 18 YEARS OLD
By initialing below, I am consenting that my parent(s) be aware of and a part of the payment and scheduling process.
Client initials*
CLIENTS UNDER 14 YEARS OLD
Under the laws of the Commonwealth of Pennsylvania, a client under 14 years of age that is seeking therapy must provide written consent from both parents. Parents must provide any court orders regarding the physical and legal custody of the child/client.

In the case of an absent parent and where there is no court order, I will make every effort to contact the absent parent to obtain consent and will document all actions taken in that regard.

Need initials of both parents/guardians.

Type N/A if not applicable.
Parent Consent*
Date

MonthDayYear
Date
Parent Consent
Date

MonthDayYear
Date
By initialing above and signing this form on the lines below, you are hereby indicating that you understand and agree to all the terms and conditions set forth herein.
Date

MonthDayYear
Date
Client signature*

Clear
Client Name Please Print*
Group Policies

By signing the below I am agreeing to the following group and workshop policies: (1.) My place in the group or workshop is reserved through a non-refundable payment of the group or workshop. (2.) I will provide a minimum of 48 hours notice if I will not be attending group. Groups are significantly affected when group members are absent. Therefore, consistent attendance is strongly encouraged. If you may be absent, your place in the group is reserved. However, please know that your group facilitator will not be able to provide the group content to you outside of the preplanned group time. (3.) I will not share other's stories from the group or workshop outside of the group or workshop. I am only allowed to share my own personal story. Otherwise what is shared in the group is confidential. (4.) Lastly, all current clients are agreeing that their original consent packet can be utilized to cover the remaining aspects of consent and all new clients (through this group or workshop) will need to additionally complete the New Client Packet, which can be found on our Client Portal or provided to you through the group/workshop leader.
Client Signature

Clear
Date

MonthDayYear
Date
Client name please print*
CONTACT INFORMATION
PHONE*
May we leave a voicemail?*

YesNo
May we leave a text?*

YesNo
Email Address*
May we email you?*

YesNo
(Note: Email is not considered a confidential medium of communication)
How did you hear about this group?
THERAPIST'S NAME*
LOCAL EMERGENCY CONTACT:
NAME*
PHONE*
RELATION*
I understand that this person will only be contacted in the event of a true emergency, where I am not able to keep myself safe or may be placing others or myself in harm.
If you've ever received therapy treatment or attended group therapy prior to now, please explain the reason and when.
Please summarize your goals, intentions, and expectations of the group.
SIGNATURE*

Clear
DATE

MonthDayYear
Date
CONSENT FOR MINOR UNDER 14 YEARS OLD

Need signature of both parents/guardians. Please provide court documentation via email to Miriah@choosingchangecounseling.com if two parent signatures do not apply.

Type N/A if not applicable.
PARENT SIGNATURE*

Clear
DATE

MonthDayYear
Date
PARENT SIGNATURE

Clear
DATE

MonthDayYear
Date
Client name please print*
CONSENT TO PROVIDE FOOD AND BEVERAGES
Names of Attendee:
Do we have your consent to serve food and/or beverages during the group session/workshop?

YesNo
If yes, do you/your child have any allergies?

YesNo
If yes, please list all known allergies, as well as reaction.
Date

MonthDayYear
Date
Signature

Clear
Should be Empty: