The Healing Minds Collective

The Healing Minds Collective

Presents: The Middle Ground, a Youth Therapeutic Group
This Is Where the Story Starts……..

Every story deserves a space. Let’s start here! Before they join the group, we need to know who they are, what they’ve been through, and how we can show up for them the right way mentally, emotionally, and spiritually! This is the first step in their healing. Let’s do this, COLLECTIVELY! “The Greatest Human Act, is to Inspire” -Nipsey Hussle
Participants Information
Participant Full Name*

First NameLast Name
Birth Date*

MonthDayYear
Grade
Gender

MaleFemale
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Transportation

Daily Transportation provided for Qualified Participants.
Please Select One*

Will Require TransportationWill Not Require Transportation
Parent/Guardian Information
Name

First NameLast Name
Home Number
Cell Number
E-mail
example@example.com
Program Goals & Interests
What are your goals for your child’s participation? (select all that apply)

Emotional regulationConfidence buildingSocial and peer skillsAcademic supportCoping strategiesLeadership and character development
Medical and Behavioral Background

Please complete this section thoroughly to help us provide safe and supportive care.
Does your child have a diagnosed mental health condition or behavioral concern?*

YesNo
If Yes, please list the diagnosis.
Is your child currently receiving therapy or counseling?

YesNo
If yes, please provide the providers name and contact information.
Billing & Insurance Information (confidential use only)

This section is required for Medicaid billing and verification. All information is encrypted and kept HIPAA compliant.
Please Select Which Applies for Payment of Services:

Medicaid BillingPrivate Pay
Insurance Provider Name*
Enter the name of your child’s Medicaid or private insurance provider. (e.g. Paramount, Molina, United healthcare).
Member ID / Medicaid Number*
This can be found on the front of your child’s insurance card.
Participants Social Security number (only for Medicaid billing services)*
Used only for Medicaid billing. this information is encrypted and securely stored.
Group Number (if applicable)*
Some plans have a group number listed on the card. Leave blank, if not applicable.
Policy Holder First Name*
Relationship to Participant*
Emergency Information
Emergency Contact's Name*

First NameLast Name
Relationship
Phone Number*
Does the participant have any allergies, chronic illness, or medical conditions? If yes, please describe.
Is the participant prescribed any medications or medical devices (such as an inhaler or EpiPen)? If yes, please explain any instructions.
Consent & Privacy Acknowledgment

I hereby give my full consent for my child’s participation in all therapeutic, recreational, and enrichment activities provided by The Healing Minds Collective LLC under The Middle Ground program.

I understand that all efforts will be made to provide a safe, supportive environment focused on mental health and youth development. I acknowledge that participation may include therapeutic group activities, movement-based sessions, emotional exploration, and community-based learning. My child may also travel to and from related events or field trips.

I understand that as part of their enrollment, my child will complete an initial clinical assessment provided by Empowered for Excellence to help determine their needs and develop an individualized support plan. This assessment is a standard part of our program and supports eligibility for services.

While we take every measure to ensure safety, I acknowledge that participation in any group program may involve some risk. By enrolling my child, I agree to release The Healing Minds Collective LLC, its Founder, staff, volunteers, and community partners from any liability in the rare event of an accident or injury during program activities or transportation. I understand that my child’s emotional, physical, and mental well-being is always the program’s top priority.
Medical Release and Authorization

As the parent and/or legal guardian of the participant, I authorize The Healing Minds Collective LLC, Empowered for Excellence, and their designated staff to seek emergency medical care for my child in the event of an accident, injury, or serious illness that requires immediate attention.

I give permission for a licensed healthcare provider to administer necessary care, including diagnostic procedures, minor treatment, or emergency intervention, should efforts to contact me be unsuccessful. I understand that every reasonable attempt will be made to reach me before proceeding with any major medical decision.

This authorization also permits staff and volunteers to provide immediate first aid and emergency care as needed until professional medical help is available.

This release remains valid throughout the duration of my child’s participation in the program and any related events or sessions.
Youth Stipend Understanding

The Middle Ground is committed to teaching life skills, responsibility, and personal growth. As part of our incentive-based model, youth participants may be eligible to receive a monthly participation stipend to recognize their consistency, respect, and effort throughout the program.

Stipend Details:

Youth participants can earn $150 per month.
Stipends are paid on the last group session of each month.
Youth must attend all scheduled sessions that month to receive the full amount
Participation, respectful conduct, and engagement in group activities are required.
Missed sessions, disrespectful behavior, or failure to complete group tasks may reduce or remove stipend eligibility.
This stipend is an earned privilege, not a guaranteed payment.

Parent Acknowledgment

I understand that my child may earn a $150 monthly participation stipend based on attendance, behavior, and engagement.

I understand that the stipend is paid at the end of each month and is not guaranteed.

I support The Healing Minds Collective LLC in using this incentive to promote responsibility and growth.
What Information Is Being Shared

To ensure your child receives the best care possible, we partner with Empowered for Excellence Behavioral Health. As part of our collaboration, certain information from this intake form will be shared securely to support clinical assessments, eligibility for services, and treatment planning.

Please see below for a visual reference of the Empowered for Excellence Intake Packet.

While this packet is displayed for transparency, all required questions have already been built into this digital form for your convenience.

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Acknowledgment & Digital Signature Consent: By signing below, I confirm that I have reviewed the information above, including the Empowered for Excellence intake packet provided for reference. I understand that the personal, medical, and behavioral information collected through this digital form will be securely shared with Empowered for Excellence Behavioral Health in partnership with The Healing Minds Collective LLC. I acknowledge that this digital form includes all required intake questions and serves as my official consent to services and information sharing between both agencies. I understand that my electronic signature below is legally binding and will serve as my full authorization for intake and participation.

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Date

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Date
Please Select Time and Date For Clinical Assessment *
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The Healing Minds Collective

This Is Where the Story Starts……..

Participants Information

Transportation