Nourish and Nature 2026 Family Group Counseling Registration

Introduction
Dear Parent/Guardian

My name is Jordan Markiewicz and I am a counselor at the Youth and Family Project, Inc. The agency has been providing supportive services to youth since 1975. The Community Counseling Program offers free group counseling services for children and youth in Washington County. Services are flexible and provided in a variety of locations including schools, libraries, and community centers. I am currently an LPC-IT with 4+ years of experience in working with youth from a variety of backgrounds. I am receiving clinical supervision from agency Executive Director Emily Greene, LPC.

The Youth and Family Project will offer free group family counseling services at Riveredge Nature Center on every Wednesday, September 16 - November 18 from 5:00-7:00 pm. Through this group we aim to bring families together in nature to strengthen connections, improve communication, and support mental well-being. Families will work collaboratively to create a meal and enjoy dinner together. Along with making fun family memories, participants will learn simple ways to improve their daily mental well-being.

If you consent for you and your child(ren) to participate in this group, please complete the digital registration form. If you have any questions about the group or the service provided by YFP, please contact me at: jmarkiewicz@YouthAndFamilyProject.org.

Thank you,

Jordan Markiewicz, LPC-IT

Counselor
Groups will be held rain or shine, but the cooking portion of the group will take place primarily indoors. Please dress appropriately for the weather and outdoor activity.
- Wear comfortable outdoor hiking boots/shoes
- Wear long pants and long socks (to avoid ticks)
- Apply sunscreen prior to attending
If there are days that are raining, we will have access to an indoor space; however, we will cancel for severe weather.

Please arrive promptly at 5:00 pm. Facilitators will allow no more than 5 minutes to accommodate late arrivals.

Family Information
Will a spouse, partner, or another adult be attending groups with you and your family?
How many children are in your family?
How many members of your family (including yourself if applicable) will be attending groups?
This question is for planning purposes to ensure adequate supplies.
Family Income Level
For Data Reporting Only
Please list any food allergies, dietary restrictions, or medical concerns within your family that staff should be aware of:
Ex: wheat, gluten, eggs, soy, nuts, peanuts, dairy, etc.

Primary Parent or Guardian

This form should be filled out by the adult registering and attending groups with the children.
Name

First NameLast Name
Preferred Name/Nickname
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Race and Ethnicity
White, Hispanic, Black, American Indian, Multiple Races, etc.
Relationship to Child(ren)
Email Address
example@example.com
Contact #
Primary Address

Address

Street Address Line 2

CityState

Zip
Are there any concerns about mental health issues, and if so, have they been formally diagnosed? If yes, please provide the date of diagnosis and history of treatment services.

Spouse, Partner or Other Adult
Name of Spouse, Partner or Other Adult

First NameLast Name
Relationship to Children
Does this adult live at the same address?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Other Adult Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Race and Ethnicity of Other Adult
Are there any concerns about mental health issues, and if so, have they been formally diagnosed? If yes, please provide the date of diagnosis and history of treatment services.

Child 1
Name

First NameLast Name
Preferred Name/Nickname
Do they live at the same address as you?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender
Race and Ethnicity
What school are they enrolled in?
Are there any concerns about mental health issues, and if so, have they been formally diagnosed? If yes, please provide the date of diagnosis and history of treatment services.

Child 2
Name

First NameLast Name
Preferred Name/Nickname
Do they live at the same address as you?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender
Race and Ethnicity
What school are they enrolled in?
Are there any concerns about mental health issues, and if so, have they been formally diagnosed? If yes, please provide the date of diagnosis and history of treatment services.

Child 3
Name

First NameLast Name
Preferred Name/Nickname
Do they live at the same address as you?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender
Race and Ethnicity
What school are they enrolled in?
Are there any concerns about mental health issues, and if so, have they been formally diagnosed? If yes, please provide the date of diagnosis and history of treatment services.

Child 4
Name

First NameLast Name
Preferred Name/Nickname
Do they live at the same address as you?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender
Race and Ethnicity
What school are they enrolled in?
Are there any concerns about mental health issues, and if so, have they been formally diagnosed? If yes, please provide the date of diagnosis and history of treatment services.

Child 5
Name

First NameLast Name
Preferred Name/Nickname
Do they live at the same address as you?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender
Race and Ethnicity
What school are they enrolled in?
Are there any concerns about mental health issues, and if so, have they been formally diagnosed? If yes, please provide the date of diagnosis and history of treatment services.

Parent/Guardian Consent Form
Your permission is requested for your family to receive group counseling at Riveredge Nature Center with the Youth and Family Project (YFP). YFP offers free, confidential counseling services to youth in need of support and their families. If your permission is granted, your family will be matched with a masters-trained mental health counseling provider.

Counselor: Jordan Markiewicz, LPC-IT

E-mail: jmarkiewicz@YouthAndFamilyProject.org

Because counseling is based on a trusting relationship between counselor and client, the counselor will keep information shared by the client confidential except in certain situations in which an ethical responsibility limits confidentiality. It is important to the therapy process that he/she does not think the parent and the therapist are conspiring against him/her in any way. There are times when students divulge information that should be shared with parents. The counselor will encourage them to do so or request permission to discuss the matter with a parent or guardian. This will be done when the counselor feels it is in the best interest of your son or daughter. As mandated reporters, there are also several situations in which YFP counselors are required by law to share details of a counseling session with the appropriate authorities. These situations include:
- Situations in which the counselor believes that the student is a threat to himself/herself or others
- When the communications involve information regarding child abuse, child neglect, or abuse of the elderly
- When the communications involve information regarding inappropriate sexual contact with a minor child
- When the client becomes a litigant in a court proceeding
- When the counselor discusses case work with his/her individual and/or group supervisor
By signing this form, I give my informed consent for my family to participate in counseling. I understand that anything that my family shares will be kept confidential except in the above-mentioned cases.

Program Participation

I understand that Nourish & Nature is part of The Youth and Family Project’s Fall 2026 Nature Groups. This program includes family-based activities where caregivers and children may participate in food preparation, meal assembly, shared dining, and related family connection activities.

I understand that caregivers are expected to remain present and actively supervise their child or children throughout the program.

Kitchen and Food Safety

I understand that participation may include the use of kitchen tools and materials such as mixing bowls, measuring cups, utensils, kid-safe knives, cutting boards, stovetop or crock pot areas, food preparation stations, and shared serving areas.

I agree that my family will follow staff directions, use kitchen materials safely, wash hands before food preparation, and participate in a respectful and safe manner.

I understand that this program includes food preparation, shared meals, and food served in a group setting. While The Youth and Family Project staff will make reasonable efforts to follow safe food handling practices, I understand there is always some risk of foodborne illness when preparing, handling, serving, or eating food.

Food Allergies and Dietary Restrictions

I understand that meals may include common allergens, including but not limited to dairy, wheat/gluten, eggs, soy, nuts, peanuts, sesame, and other ingredients.

I understand that Youth and Family Project cannot guarantee an allergen-free environment.

Assumption of Risk

I understand that participation in food preparation, shared meals, kitchen activities, and group programming may include certain risks, including but not limited to foodborne illness, allergic reactions, choking, minor cuts, burns, slips, falls, or other injuries.

By signing this form, I acknowledge these risks and agree that my family is participating voluntarily.

Medical Care

In the event of an emergency, I authorize The Youth and Family Project staff to seek emergency medical assistance if needed. I understand that staff will make reasonable efforts to contact me and/or the emergency contact listed above.

Caregiver Agreement

By signing below, I confirm that I have read and understand this waiver. I agree to remain present during the program, supervise my child or children, inform staff of any allergies, dietary restrictions, medical concerns, or safety concerns, and support my family in following program safety expectations.
I understand that through participating in this program, my child will be spending time in nature and walking on uneven terrain in a variety of weather conditions. There is also potential for encounters with wildlife such as insects like mosquitos or ticks. I acknowledge that there are inherent risks associated with this activity and my child's participation is voluntary. As such I assume all risk and release the Youth and Family Project and Riveredge Nature Center from liability for any resulting injuries or damages.
Parent/Guardian Signature
Date

MonthDayYear
This consent will be on file throughout the time that your child participates in services. You may revoke this consent at any time. Please feel free to call if you have questions, comments, or concerns, 262-338-1661 (Emily Greene, Executive Director).
Should be Empty:

Introduction

Client Registration Information

Family Information

Primary Parent or Guardian

Spouse, Partner or Other Adult

Child 1

Child 2

Child 3

Child 4

Child 5

Parent/Guardian Consent Form