Melmed Center
  • Home
  • Services
    • Developmental Medical Care
    • Psychology
    • ABA Services >
      • In-Home Therapy
      • Parent Implemented ABA
      • Parent Academy
      • PEERS® Social Skills Group >
        • PEERS® for Adolescents
        • PEERS® for Young Adults
      • Vocational Group Training
      • ABA Staff
    • Occupational Therapy
    • Group Treatment
    • Educational Advocacy
    • Nutritional Therapy
  • Patient Forms
  • Staff
    • Providers
    • Support Staff
  • Contact Us
  • Careers
  • Policies/F.A.Q.'s
  • Resources
  • About Us
  • Research Studies

    Program Application

    General Information

    [object Object]

    Medical Information

    choose all that apply
    Max file size: 20MB

    Other Activities 

    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. Information 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 sessions, 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 shared. 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. Individual 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 due 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 difficulty adapting to the telehealth format, we may ask you assist by providing rein forcers or participating 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 above stated terms and conditions. 
Submit
 4848 E. Cactus Rd. Ste. #940, Scottsdale, AZ 85254 | Phone (480) 443-0050 | Fax (480) 443-4018 | Toll Free 877-587-1770 |
Follow us on Facebook | Instagram
Resources
Policies/FAQ's 
Contact Us
Careers