Badger Middle School Registration Form Fall 2023

Introduction
Dear Parent/Guardian

My name is Jordan Markiewicz and I am a counselor at the Youth and Family Project, Inc. The agency has been providing supportive services to youth since 1975. The Community Counseling Program offers free group counseling services for children and youth in Washington County. Services are flexible and provided in a variety of locations including schools, libraries, and community centers. I am currently an LPC-IT with 4+ years of experience in working with youth from a variety of backgrounds. I am receiving clinical supervision from agency Executive Director Emily Greene, LPC.

The Youth and Family Project will offer group grief counseling services for children aged 5-12 at the West Bend Library on the second and fourth Wednesday of each month from 5:30-6:30 pm in the children's story room. Through this group we aim to provide education about grief, as well as coping skills and managing emotions.

If you consent for your child to participate in this group, please complete the digital registration form. If you have any questions about the group or the service provided by YFP, please contact me at: jmarkiewicz@YouthAndFamilyProject.org.

Thank you,

Jordan Markiewicz, LPC-IT

Counselor
February 12, 2025February 26, 2025March 12, 2025March 26, 2025April 9, 2025April 23, 2025May 14, 2025May 28, 2025

Client Registration Information
Youth Name*

First NameLast Name
Youth's Middle Initial
Youth's Date of Birth*

MonthDayYear
Date
Youth's Age
Youth's Preferred Name/Nickname
Youth's Race and Ethnicity*
White, Hispanic, Black, American Indian, Multiple Races, etc.
Parent/guardian Email Address*
example@example.com
Parent/guardian Contact #*
Whose Number? (ex. Parent's Cell, Mom's Work, Youth's Cell)
Youth's Primary Address*

Address

Street Address Line 2

CityState

Zip
Name of School Youth is Enrolled In*
Youth's Current Grade Level*
Family Information
Parent Guardian Information (Please provide information for each parent or guardian, including stepparents, to help us better understand the client's family situation).
Sibling Information (please provide information about each sibling to help us better understand the client's family situation).
Are there any concerns such as food allergies (in case we bring snacks), diagnosed or suspected mental health issues, suicidal thoughts or behaviors, anger management, etc. the counselor should be aware of?
YesNo
Are there other topics you would like to see covered in future sessions/groups?
This could include future groups for youth, parent educational sessions, etc.

Parent/Guardian Consent Form
Your permission is requested for your child,{youthName} to receive group counseling at West Bend Library with the Youth and Family Project (YFP). YFP offers free, confidential counseling services to youth in need of support and their families. If your permission is granted, your child will be matched with a masters-trained mental health counseling provider.

Counselor: Jordan Markiewicz, LPC-IT

E-mail: jmarkiewicz@YouthAndFamilyProject.org

Because counseling is based on a trusting relationship between counselor and client, the counselor will keep information shared by the client confidential except in certain situations in which an ethical responsibility limits confidentiality. It is important to the therapy process that he/she does not think the parent and the therapist are conspiring against him/her in any way. There are times when students divulge information that should be shared with parents. The counselor will encourage them to do so or request permission to discuss the matter with a parent or guardian. This will be done when the counselor feels it is in the best interest of your son or daughter. As mandated reporters, there are also several situations in which YFP counselors are required by law to share details of a counseling session with the appropriate authorities. These situations include:
- Situations in which the counselor believes that the student is a threat to himself/herself or others
- When the communications involve information regarding child abuse, child neglect, or abuse of the elderly
- When the communications involve information regarding inappropriate sexual contact with a minor child
- When the client becomes a litigant in a court proceeding
- When the counselor discusses case work with his/her individual and/or group supervisor
By signing this form, I give my informed consent for my child to participate in counseling. I understand that anything that my child shares will be kept confidential except in the above-mentioned cases.
Parent/Guardian Signature*

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Date

MonthDayYear
This consent will be on file throughout the time that your child participates in services. You may revoke this consent at any time. Please feel free to call if you have questions, comments, or concerns, 262-338-1661 (Emily Greene, Executive Director).
Should be Empty:

Introduction

Client Registration Information

Family Information

Parent/Guardian Consent Form