E-Gen Program

E-Gen Program: Consent Form

Empowered Generations (eGen) is a positive behavior support program for parents/caregivers of children ages 3-8 years old. eGen is strengths-based, culturally responsive, brief (intake plus 6 sessions June-August), billable to insurance, online, based on evidence-based programing (Generation PMTO), and linked to powerful outcomes for parents and children. The core components and skills parents will learn are encouraging positive behavior, effective communication, limit setting, positive involvement, clear directions, and emotion regulation. Please complete the information below to get started.
Child's Information
Name*

First NameLast Name
Child's 2025-2026 Grade:
Child's date of birth:*

MonthDayYear
Date
Child's legal sex for insurance purposes:*
Child's pronouns:

He/himShe/herThey/themOther
Child's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Email*
example@example.com
Parent/Guardian Phone Number*
Please enter a valid phone number.
How did you hear about the program?

School contact (teacher, social worker, etc.)Community EducationFlyer/marketingWebsiteLibraryFamily/friendChildcare siteAnother agencyOther
Insurance and Payment Information

Please provide the child's Medical Insurance information or type in "None" if they currently do not have insurance or do not wish to use insurance. Please list both primary and secondary policies if applicable.
For a list of commonly accepted insurances, please visit our FAQ page: https://www.relatemn.org/resources/faqs/
Insurance Provider (i.e. MA, Health Partners, Blue Cross):*
Group Number*
Insurance ID Number*
Medicaid or PMI # (if applicable)
In order to provide an estimation of benefits, a photo of the student's insurance card is required.

Cancelof
I would like to connect with someone at Relate about financial assistance:

YesNo
Child's Demographic Information
Child's Race*

American Indian or Alaskan NativeAsianBlack/African AmericanNative Hawaiian or Pacific IslanderWhiteDecline to AnswerOther
Child's Ethnicity*

Hispanic or LatinoNot Hispanic or LatinoBoth Hispanic and Non-HispanicDecline to Answer
Child's Primary Language*

EnglishSpanishArabicKhmerFrenchGermanHmongKarenLaoLiberianChinese/MandarinOromoSomaliVietnameseOther
Consent for Treatment
Consent for Treatment: The family will receive mental health services by a clinician from Relate Counseling Center. Engaging in services is optional and can be terminated at any time.

Client Rights and Privacy: Please view the Privacy Practives and Client Rights for Relate Counseling Center here - https://www.relatemn.org/about/intake-notices/

Email/Text: Relate Counseling may engage you or your family via email or SMS (text message) for the pupose of scheduling, obtaining feedback about services, and providing updates about the agency. Privacy cannot be guardanteed for electronic communications so should never be used for urgent matters or therapy needs. You may opt out of these communication methods at any time but replying STOP to text messages and unsubsciribing via email message.
Consent to Bill Insurance
Insurance Plans Accepted: Most commericial plans (BCBS, Aetna, HealthPartners, etc.), Medicare, Medical Assistance, Pre-paid Medical Assistance Program. You are responsible for providing a copy on the insurance card so that we can verify your benefits and provide you an estimate.

Payment Responsibility: Relate will submit claims to insurance companies on your behalf and you are authorizing Relate to be paid directly by the insurance company. You will be responsible for payment if insurance denies coverage.

Responsible Party: The person who completes this form is responsible for payments. Relate does not split medical bills amongst multiple parties.

Privacy: Information we receive from you will be shared with insurance companies for billing purposes only as needed. Patient records, including billing records, are protected under confidentiality regulations.

Cancellation Fee: Relate requires 24 hours notice of cancellations to avoid a $50 no-show/cancellation fee, except in emergencies.

Financial Assistance: available via application on our website (www.relatemn.org).
Consent for Information Sharing
Privacy: The family's information is private and won’t be shared outside the organization without your permission. Consent can be withdrawn at any time.

Demographics: Demographic information is gathered for the purpose of grant reporting. It is always de-identified.

Exceptions: There are certain situations where Relate may have to share information without permission:
-If someone is a serious threat to self or others.
-If there is a report of abuse or neglect of a child or vulnerable adult.
-If a court orders Relate to provide information about treatment.
Non-Discrimination Notice: Relate Counseling Center does not discriminate on the basis of race, color, national origin, sex, age, or disability. We provide accommodation for people with disabilities in a timely manner and free of charge when they are needed to perform services. Relate provides language assistance services for people with limited English proficiency, also free of charge. Please alert us if you would benefit from any accommodation.
If you have any concerns about our policies, please contact the Human Resources Director at Relate Counseling Center by calling 952-932-7277. You may also file a complaint with the Office for Civil Rights by email: OCRformsubmissions.dot@state.mn.us or phone: 651-366-3073.
Agreement

By signing your name below, you agree to the information listed above. You are also stating that you have legal permission to provide consent for the child named in this form.
Signature*

Clear
Should be Empty:

E-Gen Program: Consent Form

Child's Information

Insurance and Payment Information

Child's Demographic Information

Consent for Treatment

Consent to Bill Insurance

Consent for Information Sharing

Agreement