The Girl Code
Youth Therapeutic Mentorship
The Girl Code
Before your daughter, niece or little sister steps into this space, we want to know who she truly is! Beyond the filters, the pressure, and the world’s expectations. The Girl Code is about creating safe, affirming space where young women can show up fully- mentally, emotionally and unapologetically! This is more than a program. It’s a healing circle, a confidence builder and a sisterhood. We meet each girl where she is and together, we unpack what it means to love yourself out loud because even in their teens, our girls deserve soft, landings bold truths, and real support.
Participant Information
Participants Name
*
First Name
Last Name
Date of Birth
*
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Month
/
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
School and Grade Level
Transportation
Please Select One
My child will need transportation to attend the program
My child NOT need transportation and will be dropped off and picked up
My child can ONLY attend if transportation is provided
Parent/Guardian Information
Parent’s Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Program Goals & Interests
What are your goals for your child's participation? (select all that apply)
Emotional regulation
Confidence building
Social and peers skills
Academic support
Coping strategies
Character development
Medical & Behavioral Background
Please complete this section throughly to help us provide safe and supportive care.
Does your child have a diagnosed mental health condition or behavioral concern?
Yes
No
If yes, please briefly describe diagnosis, support needs, or any helpful information .
Is your child currently receiving therapy or counseling?
Yes
No
If yes, please provide the providers name, and contact information.
Billing & Insurance (confidential use only)
This section is required for billing and verification. All information is encrypted and kept HIPAA compliant.
Please Select Which Applies for Payment of Services:
Medicaid Billing
Private 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.
Participant SSN (only used 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 Name
Last Name
Phone Number
Please enter a valid phone number.
Relationship
Medical Release and Authorization
as the parent or legal guardian of the participant I authorize the healing mind collective LLC and 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 any necessary care, including diagnostic procedure, minor treatment, or emergency intervention should effort to contact me be unsuccessful. I understand that every reasonable attempt will be made to reach out to me before proceeding with any major medical decision. This authorization also permit staff and volunteers to provide immediate first aid and emergency care as needed until professional medical help is available, I release remains valid through the duration of my child’s participation in the program in any related events or sessions.
Does the participant have any allergies chronic illness or medical conditions? If yes, please describe.
Is the participant prescribed any medication’s or medical devices (such as an inhaler or an EpiPen)? If yes, please explain any instructions.
Consent & Privacy Acknowledgement
I hear I give my full consent for my child’s participation in all therapeutic recreational and enrichment activities provided by the healing mine collective under the little minds big feelings 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 base sessions, emotional exploration, and community based learning, my child may also travel to and related events or field trips. I understand that as a part of their enrollment my child will complete an initial clinical assessment provided by Empowered For Excellence to help determine their needs and development and individualized support plan. This assessment is a standard part of our program and support eligibility for service. 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 mines collective LLC. It’s founder, staff volunteer, 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 programs tap prior..
What information is being shared?
To ensure your child receive the best care possible we partnered with Empowered For Excellence behavioral health as a part of our collaboration certain information from this intake form will be shared securely and 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.
Please Sign Below:
*
Acknowledgment in 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 and 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 service 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.
Please Select a Day & Time for Clinical Assessment
*
Private Pay
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Monthly Private Pay
Private Pay Rate: $150/month Includes all group sessions, workshops, and wellness materials. Limited spots available. Payment plans upon request.
$
150.00
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Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
Google Pay
After submitting the form, you will be redirected to Google Pay to complete the payment.
Cash App Pay
After submitting the form, you will be redirected to Cash App Pay to complete the payment.
ACH Bank Transfer
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