NJ4S Tier 2 Group v2

Family Connections’ NJ4S-Essex offers skill-building groups for youth in grades 6-12. The groups give youth the opportunity to discuss challenges they face with peers in a safe setting and are designed to inspire student success in school and life.

TOPICS INCLUDE:
- Bullying Prevention
- Healthy Connections with Peers
- Healthy Dating and Relationships
- Mental Health and Wellbeing
- Sexual Health and Pregnancy Prevention
- Social and Emotional Wellness
- Support for LGBTQIA+ Youth
- Understanding the Impact of Trauma
- Substance Use Prevention
- Grief Support
Groups will be offered in schools during the day or after school. The groups vary in duration from 45 minutes to 1 hour. The cycles can be 6-12 weeks in length depending on the topic. The school representative will give you additional details on the group topic, meeting time, and duration of the group cycle.

For youth: I hereby consent to be an active participant in NJ4S-Essex groups.
Participant Name*

First NameLast Name
Participant Signature*

Powered by Jotform SignClear
Date*

MonthDayYear
Date
Date Of Birth*

MonthDayYear
DOB
Age*
Participant's School*
Participant's Grade*
Participant's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
For parents: I consent for my child to participate in NJ4S-Essex groups.
Parent/Guardian's Name*

First NameLast Name
Parent/Guardian's Signature*

Powered by Jotform SignClear
Date*

MonthDayYear
Date
Participant's Cell Number*
Please enter a valid phone number.
Participant Parent/Guardian Cell Number*
Please enter a valid phone number.
Best number to be reached
Please enter a valid phone number.
For further information, contact NJ4S at:
Email: infonj4sessex@familyconnectiosnj.org
Family Connections NJ4S-Essex
7 Glenwood Avenue Suite 304, East Orange, NJ 07017
973-323-3451

NOTICE OF PRIVACY PRACTICES

This Notice of Privacy Practices describes how Family Connections may use and disclose your protected health information (PHI) to carry out treatment, payment, or health care operations and for other purposes that are permitted or required by law. This Notice further states the obligations we have to protect your health information. It is our duty to maintain the privacy of PHI, to abide by the terms of the privacy notice currently in effect, and to provide individuals with notice of its legal duties and privacy practices relative to PHI. This Notice also describes your rights regarding the health information we maintain about you and a brief description of how you may exercise these rights. Please review it carefully. If you have any questions about this Privacy Notice, please discuss them with a Family Connections Program Manager. You may also contact our Privacy Officer at 973-675-3817.
Should be Empty: