Healing Connection Middlers Grief Group Registration Form

Healing Connection Middlers Grief Group Registration Form

Please fill out the form to register and provide parental consent. Have your PayPal details ready for payment.
Participant's Full Name*

First NameLast Name
Participant's Date of Birth*

MonthDayYear
Date
Parent/Guardian Full Name*

First NameLast Name
Parent/Guardian Email Address*
example@example.com
Parent/Guardian Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
I am the parent or legal guardian of the child named above, and I give permission for my child to participate in Healing Connection, a grief support group facilitated by Sherrye Urtz, LCPC, CBCP, through Healing By U, LLC.*
I understand that this group is intended to provide supportive, age-appropriate grief education, emotional support, coping skills, and opportunities for connection with peers who have experienced loss. Group activities may include discussion, sharing, expressive activities, and skill-building exercises.*
I understand that participation in a grief group may involve discussing difficult emotions and personal experiences related to loss. While many children benefit from this process, participation may sometimes bring up sadness, worry, anger, or other strong feelings.*
I understand that information shared by my child with the facilitator will be treated with professional confidentiality consistent with applicable law and professional ethics. However, I understand that confidentiality is not absolute. Information may be disclosed when required or permitted by law, including but not limited to situations involving concern about danger to self or others, suspected abuse or neglect, medical emergency, court order, or other legal requirements.*
I understand that this is a group service. The facilitator will encourage all group members to respect one another’s privacy and keep what is shared in group confidential. However, I understand that confidentiality by other group participants cannot be guaranteed.*
I understand that this group is not emergency care, crisis response, or a substitute for a higher level of treatment when needed. If my child is experiencing an emergency or urgent safety concern, I understand I should call 911, go to the nearest emergency room, or contact 988.*
I authorize the facilitator to communicate with me regarding scheduling, attendance, participation concerns, and safety-related issues. I understand that some clinical details may be handled in accordance with Maryland law and professional judgment, particularly for children old enough under Maryland law to have certain consent and confidentiality rights.*
*
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Grief Counseling Group Registration
Fee for participation in the counseling group (ages 10-14)

$265

Total

$0.00
Payment Methods

Choose from one of the PayPal options to make your payment.
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