Child Anxiety Group Participation

Child Anxiety Group Participation
Child Information
Child's Full Name

First NameMiddle NameLast Name
Date of Birth
Age
School
Grade
Parent/Guardian Information
Parent/Guardian Name

First NameLast Name
Relationship to Child
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number
Please enter a valid phone number.
Email
example@example.com
Emergency Contact

(If parent/guardian cannot be reached)
Name

First NameLast Name
Relationship to child
Phone Number
Please enter a valid phone number.
Insurance Provider
Policy/Member Number
Group Number (if applicable)
Policy Holder's Name
Policy Holder's Relationship to Child
Policy Holder's Date of Birth
Insurance Provider Phone Number
Please enter a valid phone number.
Authorization/Referral Required?

YesNo
Anxiety Group Information
Group Name
Meeting Location

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Meeting Schedule
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Group Facilitator(s)
Consent and Authorization
I, , as the parent/legal guardian of , give my consent for my child to participate in the anxiety group program described above.
I understand and acknowledge the following:
1. Nature of the Group: The anxiety group is designed to provide support, education, and coping strategies for children experiencing anxiety. It is not intended as a substitute for individual therapy or medical treatment.
2. Confidentiality: Information shared in the group will be kept cofidential by the facilitators within the limitations of the law. Exceptions to confidentiality include: risk of harm to self or others, suspicion of abuse or neglect, or a court order.
3. Group Format: I understand that this is a group-based program and that my child will participate with other children under professional facilitation.
4. Insurance and Payment: I authorize the release of any information necessary to process insurance claims related to my child's participation. I understand that I am Þnancially responsible for any charges not covered by my insurance.
5. Emergency Medical Authorization: In the event of a medical emergency, I authorize the group facilitators to secure appropriate medical treatment for my child if I cannot be reached.
6. Permission for Assessment: I give permission for my child to complete questionnaires or assessments related to measuring anxiety symptoms and progress in the group.
7. Right to Withdraw: I understand that I have the right to withdraw my child from the group at any time.
8. Risks and Benefits: I understand that while the anxiety group may help my child develop coping skills, there is no guarantee of specific outcomes. Though uncommon, potential risks may include temporary increases in anxiety when discussing challenging topics.
Additional Information
Please provide any information that would be helpful for the group facilitators to know about your child (allergies, medications, specific concerns, accommodations needed, etc.):
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Date

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This form must be completed and returned prior to your child's participation in the anxiety group.
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Child Anxiety Group Participation

Child Information

Parent/Guardian Information

Emergency Contact

Anxiety Group Information

Consent and Authorization

Additional Information