• RSP Test Form

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Who is completing the client services agreement?*

  • Participant Information

  • Participant Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year

  • It looks like the participant is {age} years old. 

    Unfortunately, the law says you are too young to consent for yourself. You will need your parent or guardian to fill out this form on your behalf.

  • It looks like the participant is {age} years old.

    Unfortunately once a participant is 18 or older they are required to sign on their own behalf. Please have the participant fill out this form.

  • Consent Type
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Information about the Resilient Scholars Project

  • The above-named participant has been referred by his/her/their school to participate in the Resilient Scholars Project – School Based (RSP-SB) Trauma or Grief Services. Participation is voluntary, and there is no charge to participate. Therapy services will be held once per week during the school year, resulting in approximately 15-20 sessions. Over the summer, services will typically be held twice a week, resulting in approximately 10 sessions for summer partners. A licensed therapist(s), or a graduate intern, associate, or fellow under the supervision of a licensed therapist(s) from the Wendt Center for Loss and Healing will provide the therapy.

    Events such as abuse, deaths of loved ones, witnessing or living in violence, sudden loss of home and belongings, etc., can be distressing. These events can cause problems that continue long after the event is over. These events may cause issues such as trouble sleeping, difficulty concentrating or focusing, behavioral/emotional changes, and poor school or work performance.

    RSP-SB Trauma and Grief Therapy Services have been developed to help participants learn about grief and trauma and the mental, physical, and emotional impacts. RSP-SB introduces participants to new and practical ways to solve problems and to manage behavior and feelings. In previous years, the majority of participants who completed the program reported fewer difficulties from their experiences of loss and/or trauma afterwards. We hope that the participant will report feeling and doing better at school after completing this program.

    Sometimes, participants may feel sad or other difficult emotions during RSP-SB and while talking about their experiences of loss and/or trauma. This is a typical response expected from participants. At any time during group or individual therapy you are welcome to reach out to the therapist(s) and request updates or ask questions about therapy.

    We evaluate our program by looking at participation in therapy, pre- and post-assessments conducted by our team, and feedback from you, school/community agency personnel, and RSP-SB staff. For each participant who is referred and has a signed agreement on file, we will attempt to assess them at their school/partner organization to determine eligibility for the program. If we determine they are not eligible, or that there is not capacity to serve them, we will attempt to provide recommendations for other appropriate services.

  • Informed Consent for Services

  • By signing this consent and release of information form, you give permission for yourself or your child to be assessed for eligibility and to participate in Resilient Scholars Project – School Based Trauma or Grief Therapy Services. If the participant is eligible and enrolled in the program:

    1. The Wendt Center will provide weekly group or individual therapy to the participant. Participation is voluntary, and they may request to cease participation at any time. The clinician may want to discuss this with the participant, school staff and/or the caregiver(s), but you and they reserve the right to end treatment without discussion.
    2. In some situations, a clinician may decide it is not in the participant, the group, or the therapist’s best interest to continue therapy. Reasons can range from lack of attendance, difficult behaviors in the therapy environment, difficulty engaging in work related to grief and/or trauma, or educational factors such as the participant’s schedule. If this happens, a recommendation will be made to the school as to what type of services may be more appropriate or effective.
    3. The Wendt Center therapist is required to keep accurate electronic medical records, including information on participant demographics, assessment results, and history. Our system also requires that we place a professional diagnosis on file. We may be required to submit some or all of this information to the funder for your child’s services, anonymized and in aggregate (combined) with the other participants in services.
    4. The Wendt Center therapist will speak with the school/organization staff and/or teachers connected to the participant’s progress in the Resilient Scholars Project.
    5. The Wendt Center therapist will not conduct a therapy session if the participant appears to be under the influence of drugs or alcohol, engaging in violent or dangerous behavior, or communicating in language that is offensive. Any such behavior places their enrollment in services in jeopardy, and they may be discharged at the discretion of the therapist.
    6. The Wendt Center will not offer court testimony, provide fitness assessments or custody recommendations, write qualifying opinions for the court system on behalf of clients, nor appear voluntarily for legal proceedings.
    7. The Wendt Center does not provide 24-hour crisis care. In the case of an emergency during non-office hours, participants must contact the District of Columbia’s emergency Access Help Line (1-888-793-4357), Suicide and Crisis Lifeline (988), Crisis Link (1-800-784-2433), or dial 9-1-1 in case of a life-threatening emergency.
    8. The Wendt Center will complete an assessment with the participant at the end of therapy. The Wendt Center cannot guarantee the results of treatment, but is happy to speak with you about the participant’s progress and any future recommendations for services.
    9. This Informed Consent is not intended to be “all inclusive” of aspects of one’s mental health treatment. It is only intended to provide some basic information to assist in deciding to engage in treatment.

     

    Limits of Confidentiality

    The information that a participant shares during therapy is private and will not be shared with any other party with a few exceptions. However, local and federal law and professional codes of ethics require that in certain circumstances, information can and must be shared without permission. These circumstances where information cannot be kept confidential include:

    1. Suicide: if a participant is assessed to be a danger to themself; cannot guarantee their physical safety against the intention of suicide; and/or have immediate suicidal plans. Actions may be taken to ensure their safety.
    2. Homicide: if a participant is assessed to be a danger to others; cannot guarantee their safety; and/or have immediate, specific plans to cause fatal injury/harm to another person. Actions may be taken to protect the safety of others.
    3. Child or Elder Abuse/Neglect: D.C. law requires ALL mental health providers to report all suspicions/knowledge of child or elder abuse/neglect to the appropriate authorities.
    4. Court Order/ Subpoena: a therapist can be required to relinquish a copy of a participant’s written Mental Health Record to the appropriate Courts. Mental health providers can also be subpoenaed to testify in court without participants’ consent.
    5. Minors can consent to outpatient mental health treatment in the District of Columbia without parental permission or notification provided the minor is knowingly and voluntarily seeking the services and the provision of those services is clinically indicated for the minor’s well-being (DC Code section 7-1231 §7-1231.14) This includes not sharing information with parent(s)/caregiver(s)/case manager(s) without the child’s permission.
    6. Client medical records are destroyed after the legally required duration.
    7. Confidential mental health information may also be used within the Wendt Center for Loss and Healing without written permission for the purpose of coordinating services within the agency and delivering high quality care. This includes but is not limited to consultations and training with internal interns, supervisors, and other providers at the Wendt Center. In the case of any external consultations, training or case conferences with others, information will be de-identified to further protect confidentiality.

     

    Health Insurance Portability and Accountability Act (HIPAA)

    1. You may request a copy of the Wendt Center for Loss and Healing’s HIPAA Notice of Privacy Practices at any time, view it at any time, or view it on the Center’s website at www.wendtcenter.org.
    2. Participants of Wendt Center services consent to receiving necessary communications about services including appointment reminders, surveys, closure notices, and other appointment related communication. A separate form (which follows this agreement) will allow you to opt into or out of other types of communications, and you can change your selection to those optional communications at any time by emailing forms@wendtcenter.org to request a new “Additional Communications Form”.
    3. At multiple points throughout the course of treatment, an RSP-SB Newsletter will be provided. The newsletter will include information about the general content of therapy as well as learning tips that can enhance your experience and/or facilitate conversations between you and your family. The newsletter is available via printed copy and sent to the email address(es) you provided above. If you would like the newsletter sent to an additional email address, please email forms@wendtcenter.org with the subject “RSP Newsletter”.

     

  • Release of Information

  • To better serve the participant, the Resilient Scholars Project of the Wendt Center for Loss and Healing and my/my child’s school and/or community partner organization referring them have my permission to send or receive information from or to verbally discuss the participant’s progress, enrollment, and participation in the RSP-SB Trauma or Grief Therapy Services.

  • Emergency Contact Information

  • You are asked to provide contact information for at least one Emergency Contact, to be used in the case of a medical emergency. You can update these Emergency Contacts at any time by emailing forms@wendtcenter.org to request a new “Emergency Contact Form”. If you are consenting on your own behalf, the emergency contact does not need to be a guardian.

  • Consent

  • I have read, understand, and agree to the above policies, and by signing below affirm that I give permission for the below participant to be assessed for and participate in the Resilient Scholars Project – School Based Trauma or Grief Therapy Services provided by the Wendt Center for Loss and Healing. I understand the participant’s rights and responsibilities as a client and the rights and responsibilities of their therapist. I understand I can revoke this authorization and/or update my elections and information at any time by submitting a request in writing to forms@wendtcenter.org or to the participant’s assigned therapist.

  • Participant Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year

  • Emergency Contact Form

  • Below please provide contact information for at least one emergency contact. This information will only be used by the Wendt Center for Loss and Healing in the event of a medical emergency. 

    Please do not use the same information from the caregiver above unless no other emergency contact has been identified. If you are a minor, the emergency contact should be a legal adult but does not have to be your caregiver.

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Participant Date of Birth
     / /
    2 digit month, 2 digit day, 4 digit year

  • Additional Communications Form

  • As a client of the Wendt Center for Loss and Healing, I understand that I consent to receiving necessary communications about my services.

    The Wendt Center also regularly sends out communications regarding upcoming programs, events, new services, as well as fundraising appeals. Please carefully review the options below and make a selection by checking the box or boxes.

  • Additional Communications Selection

  • Regardless of your selection you will in no way be prevented from receiving services or future services from the Wendt Center as a result.

    If you wish to opt out of all additional communications, please confirm you have only selected the top box above. You may choose to change your selection(s) at any time by requesting a new version of this form to complete either at the front desk or by emailing forms@wendtcenter.org.

  • Participant Date of Birth
     / /
    2 digit month, 2 digit day, 4 digit year

  • Patient Portal Opt-Out Form

  • At the Wendt Center for Loss and Healing, we offer a secure online patient portal to allow clients to access appointment informaiton, make payments, communicate with providers, and manage certain aspects of their care.

  • Select:

  • By checking the opt-out above, I confirm that:

    • I understand that this meaans I will not receive electronic forms or messages through the portal, and that in order to access my (or my child's) health records I will need to make a request to the practice.
    • I understand that I will receive all communication by phone, email, or in person.
    • I may opt back in to the patient portal at any time by submitting a written request to my clinician or to forms@wendtcenter.org, but must follow through on completing the electronic registration within 72 hours of receiving the portal invitation.

  • If you selected that you would like to use the patient portal, below please provide the email address to which we should send the registration. Please be aware you must complete the registration within 72 hours of receiving it, or the link will expire.

  • Participant Date of Birth
     / /
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: