Polished Minds with Ms. Paige

The Healing Minds Collective

Presents: Polished Minds, A Nail Certification Course
Your Creativity. Your Confidence. Your Craft.

Polished Minds is more than a nail course. It is a space where creativity, confidence, and beauty education come together. Before joining the program, we want to know who you are, what inspires you, and how we can support your growth in a way that feels personal, empowering, and professional. Whether you are here to learn the basics, explore advanced nail artistry, or build skills for future clients, this is your space to create, grow, and shine. Let’s build something beautiful, together. "You can't use up creativity, The More You use it, the more you have" - Maya Angelou
Participants Information
Participant Full Name*

First NameLast Name
Birth Date*

MonthDayYear
MaleFemale
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Transportation

Daily Transportation provided for Qualified Participants.
Will Require TransportationWill Not Require Transportation
Program Goals & Interests
Stress Management & Emotional regulationBuilding Confidence & Self WorthParenting and Support BalanceCoping strategies for Daily ChallengesPersonal Growth and Life DevelopmentNail Skill Advancement
Medical and Behavioral Background

Please complete this section thoroughly to help us provide safe and supportive care.
YesNo
If Yes, please list the diagnosis.
YesNo
If yes, please provide the providers name and contact information.
Billing & Insurance Information (confidential use only)

This section is required for Medicaid billing and verification. All information is encrypted and kept HIPAA compliant.
Medicaid BillingPrivate 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.
Participants Social Security number (only 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*
Emergency Information
Emergency Contact's Name*

First NameLast Name
Relationship
Phone Number*

Area CodePhone Number
Does the participant have any allergies, chronic illness, or medical conditions? If yes, please describe.
Is the participant prescribed any medications or medical devices (such as an inhaler or EpiPen)? If yes, please explain any instructions.
Consent & Privacy Acknowledgment

I hereby give my full consent for my participation in all therapeutic, recreational, and enrichment activities provided by The Healing Minds Collective LLC under The Healing Room program.

I understand that all efforts will be made to provide a safe, supportive environment focused on mental health and development. I acknowledge that participation may include therapeutic group activities, movement-based sessions, emotional exploration, and community-based learning. I may also travel to and from related events or field trips.

I understand that as part of my enrollment, I will complete an initial clinical assessment provided by Empowered for Excellence to help determine my needs and develop an individualized support plan. This assessment is a standard part of our program and supports eligibility for services.

While we take every measure to ensure safety, I acknowledge that participation in any group program may involve some risk. By enrolling, I agree to release The Healing Minds Collective LLC, its Founder, staff, volunteers, and community partners from any liability in the rare event of an accident or injury during program activities or transportation. I understand that my emotional, physical, and mental well-being is always the program’s top priority.
Medical Release and Authorization

I authorize The Healing Minds Collective LLC, 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 necessary care, including diagnostic procedures, minor treatment, or emergency intervention, should efforts to contact me be unsuccessful. I understand that every reasonable attempt will be made to reach me before proceeding with any major medical decision.

This authorization also permits staff and volunteers to provide immediate first aid and emergency care as needed until professional medical help is available.

This release remains valid throughout the duration of my child’s participation in the program and any related events or sessions.
What Information Is Being Shared

To ensure you receive the best care possible, we partner with Empowered for Excellence Behavioral Health. As part of our collaboration, certain information from this intake form will be shared securely to support clinical assessments, eligibility for services, and treatment planning.

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.
Acknowledgment & 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 in 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 services 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.

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The Healing Minds Collective

Your Creativity. Your Confidence. Your Craft.

Participants Information

Transportation