BLUE UMBRELLA PSYCHIATRY VIBE & THRIVE TEEN SOCIAL SKILLS GROUP PARTICIPATION AGREEMENT & WAIVER LIABILITY
Name of teen participant
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First Name
Last Name
Name of parent guardian:
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First Name
Last Name
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth of teen participant
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number of parent for reminders
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Please enter a valid phone number.
Format: (000) 000-0000.
Email of parent
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example@example.com
Expectations of Conduct I have reviewed the group rules with my child, and we understand that "respectful participation" is essential for the safety and success of the group. We specifically agree to: Arriving on Time: We will ensure prompt arrival so the group can start and end together without disruption. Phone-Free Environment: Phones will be silenced and put away to maintain focus and respect for peers. Active Engagement: A commitment to participate in discussions and group activities. Privacy & Safety: A strict agreement to keep the identities and stories of all group members private and to speak up immediately if anyone's safety is at risk.
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I agree to the Expectations of Conduct
Self-Pay Acknowledgment I understand that this is a self-pay group. I acknowledge that the Vibe and Thrive Teen Social Skills Group is a self-pay service and is not billable through insurance under any circumstance.No Insurance Claims: I understand that Blue Umbrella Psychiatry will not submit claims to my insurance provider for this group, nor will they provide "Superbills" for out-of-network reimbursement. Payment Responsibility: I agree to the flat rate of $25.00 per session, which will be charged to my card on file. Excluded from Deductibles: I understand that these payments likely will not apply toward my insurance deductible or out-of-pocket maximum
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I understand
Facilitator & Clinical Status Disclosure Licensed Facilitators: The group may be led by Jesimar El Yamel, LMHC, or another fully licensed mental health professional. Registered Interns: The group may be led by a Registered Mental Health Counselor Intern. I understand these facilitators have completed their Master’s degrees and required supervision hours and are currently awaiting final state licensure. In accordance with Chapter 491, F.S., they continue to practice under the clinical oversight of a Board-Approved Qualified Supervisor. Master’s Level Interns: The group may be assisted or led by Graduate Student Interns from Nova Southeastern University (NSU). These are students currently completing their final clinical practicum/internship requirements. I understand they are supervised both by NSU faculty and an on-site licensed supervisor at Blue Umbrella Psychiatry. On-Premises Supervision: I acknowledge that whenever an intern (Registered or Student) is facilitating, a licensed mental health professional is physically present on the premises to ensure the highest standard of clinical safety
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I understand that the Vibe and Thrive group is facilitated by Blue Umbrella Psychiatry clinical staff, which may include professionals in various stages of licensure.
Clinical Scope & Emergency Disclaimer No Crisis Services: Blue Umbrella Psychiatry does not provide 24/7 crisis care. In an emergency (e.g., self-harm or safety risks), I will not wait for group; I will call 911, contact 988, or go to the nearest ER.Referrals: I understand that if my child’s needs exceed the scope of this group, the facilitator may recommend a higher level of care.
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I understand the clinical scope of this group. I acknowledge that Vibe and Thrive is for social skills and peer support only.Not Individual Therapy: This is a supplement to, and not a substitute for, individual therapy or psychiatric care
Consent for Minor Participation: Vibe and Thrive Teen Social Skills Group I, the undersigned, am the parent or legal guardian of teen/participant above. I give my full consent for my child to participate in the Vibe and Thrive Teen Social Skills Group hosted by Blue Umbrella Psychiatry.
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I consent
Payment Authorization: Vibe and Thrive Teen Social Skills Group I authorize Blue Umbrella Psychiatry to charge my credit card on file (or the one provided below) $25.00 per session for the Vibe and Thrive Teen Social Skills Group. Billing Frequency: I understand that my card will be charged on the day of each group session attended.Self-Pay Status: I acknowledge that this is a fully self-pay service and will not be billed to insurance. Cancellation Policy: I understand that no shows or cancellations with less than 24 hours notice may still be subject to the $25.00 session fee.
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I have read and agree to the payment terms above.
Date
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Year
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Month
Day
4 digit year, 2 digit month, 2 digit day
Date
Signature of parent/guardian
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Submit
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