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Program Application
*
Indicates required field
Are you applying for:
*
PEERS Adolescents (9-17 years old)
PEERS Young Adult (18-35 years old)
Improv
General Information
Participant's Name
*
First
Last
Date of Birth
*
Age
*
Participant Phone Number
*
Participant Email
*
Parent Name
*
First
Last
Phone Number
*
Parent Email
*
Can this parent be used as an Emergency Contact?
*
Yes
No
Parent Name
*
First
Last
[object Object]
Phone Number
*
Parent Email
*
If 18 or older - Own Guardian?
*
Yes
No
If 18 or older, do you want all communication to include your parent(s)/guardian?
*
Yes
No
Medical Information
Behavioral & Medical Diagnosis
*
ADD/ADHD
Autism
ODD
OCD
Anxiety
Depression
Learning Disability
choose all that apply
List any other behavioral or medical conditions
*
Has the participant had any recent incidents of aggression, self-injurious behavior, property destruction, or suicidal thoughts in the last 6 months?
*
Yes
No
If yes, please explain
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Has the participant ever received any psychiatric or psychological/counseling treatment before?
*
Yes
No
If yes, please explain
*
If no, please attach proof of guardianship
*
Max file size: 20MB
Other Activities
Sports
*
Hobbies
*
Volunteer Opportunities
*
Social Skills Groups
*
Other
*
Digital Signature
1. I/we hereby make an application for applicant to attend PEERS® social skills intervention program, Improv Class. I/We have filled out all of the information to the best of my/our knowledge. I/We understand that this is an application and that my teen has not been fully accepted to the PEERS® social skills intervention program or Improv at this time.
2. It may be necessary to audio or videotape assessment and/or treatment sessions for supervision, program monitoring and development, and/or training purposes. I/we understand that the recorded material will be used only by Melmed Center staff and only for purposes of supervision, program monitoring and development, and/or training. If the assessment or treatment involved formal research that goes beyond normal evaluation or clinical procedures, I/we reserve the right to consent or refuse to participate.
3. I
nformation gathered in sessions will be held confidence from sources outside the
office, unless
I/we grant written or verbal consent for exchange of information between professional or interested parties regarding the care of myself/ my child. I/we understand that the exceptions to confidentiality include suspected child abuse, a threat to harm oneself
, or a threat to harm another person. Since the Melmed Center providers work as a team, information is shared with team members on an as needed basis, for the benefit of the child or myself.
During the session
s
, myself/teens will participate in
didactic lessons and role-play demonstrations, and practice skills during online socialization activities
. The facilitator encourages the teens
to share what they wish with their parents, but generally refrains from telling parents about personal material share
d
. If topics arise that the facilitator feels parents must know, we will first review this privately with the participant then contact the parents. This way the facilitator empowers
the participant to share his/her material
.
Since my/my child’s space in the group is reserved, I/we understand that I/we pay for the series of sessions
whether or not
I/my child is able to attend due to illness, vacations, etc. In
dividual parent meetings are available for an additional cost
,
if required.
I/we understand that I/we are responsible for all fees related to PEERS® sessions, Improv Class.
Payment, in full, is du
e by the first session.
Melmed Center is happy to provide a statement at no charge
the date of the group meeting
($5/statement after the date of group meeting) for me to submit to my insurance company for possible reimbursement.
If your child has d
ifficulty adapting to the
telehealth
format
,
we may ask you
assist
by providing
rein forcers
or participat
ing
in behavior management strategies to increase
your child’s
success.
As participants you will be sharing personal information and stories. Cameras are required to be on during class so we can monitor who is present, to protect everyone’s privacy. Thank you for your understanding.
We apologize, but Microsoft Teams does not let you BCC meeting participants on invites, therefore e-mails will be shared among other class participants. This class may be recorded for quality assurance purposes.
Having reviewed the preceding, I/we consent to the participation PEERS® group, Improv Group, and agree to abide by the abo
ve stated terms and conditions.
I agree to the above consent
*
Yes
Please type your name as a Digital Signature
*
Please type Today's Date
*
Submit
