Behavior and Mental Health Please answer the following questions to the best of your ability. These questions are to help us provide the best service possible. This information is held to the same standards of confidentiality as our counseling. Please put n/a if not applicable. (Parents answer with or for minor children) Client Name * Last Client First * First Client Middle Middle Name of Parent or Guardian * Last Parent or Guardian First * First Birth Date * Age * Gender * Male Female Number of Siblings Ages Current Address * Current Address Street Street Apt., PO Box, Suite Apt., PO Box, Suite City City State AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State Zip/Postal Zip/Postal Home Phone * Cell/Other Phone Email * Referred by * Who else can pick up child other than parents (name/phone/relation) Name Additional Pick up 1 Name Phone Additional Pick up 1 Phone Relation Additional Pick up 1 Relation Name Additional Pick up 2 Name Phone Additional Pick up 2 Phone Relation Additional Pick up 2 Relation Diagnosis’s that have been given for client? * If medication is currently being taken, please list Does the client participate in the Gardiner Scholarship (PLSA)? Yes No General Health and Mental Health Information (parents answer with or for minor children) How is client’s physical health at the present time? Poor Unsatisfactory Satisfactory Good Very Good Please list any persistent physical symptoms or health concerns(e.g. chronic pain, headaches, hypertension, diabetes, thyroid dysfunction, etc.) Does client have any problems with their sleep habits? Yes No How many times per week do they exercise? Number of Days Minutes/Hours Minutes / Hours Are there any changes or difficulties with their eating habits? Yes No Have they felt depressed recently? Yes No Have they had any suicidal thoughts recently? Yes No What concerns have brought you to seek our professional services at this time? What does the client want to do with their life and what plans do they have to reach these goals? GOALS (parents answer with or for minor children) What are your social/academic/functional goals for yourself or the client over the coming year? School Information Where do you or the client attend school? What grade/level? Any retentions? Highest Degree Achieved? What type of class setting? How are grades? What type of support do you or the client get in school? Please discuss participation in any clubs, groups, or sporting activities before or after the regular school day? In the last year, has the client had any major life changes (e.g. new school, moving, illness, significant losses, relationship change, etc.)? Family Information Who does the client live with? What is the name, age, and occupation of each family members or others who lives with the client? On a scale from 1-10 (10 being great), how would you rate the quality of your family life? 1 2 3 4 5 6 7 8 9 10 Social and Behavioral Information(Parents answer with or for minor children) What does the client like to do? What are they good at? What behaviors does the client need to change? Would the client run away or leave a situation if upset? Yes No OtherOther Does the client have a history of being aggressive? If so, please explain. What specific situations or events trigger frustration or anxiety in the client? Please explain how the client relates to peers in school or in other settings (such as work). What changes in the behavior of the client or yourself have you seen lately? Does the client have sensory issues? Do they display rigid behaviors? What is their “special interest”? Behavior and Emotionality Therapy, Counseling and Training Packages Select Your Package * 3 Pack $525 5 Pack $857.50 10 Pack $1662.50 Insurance Information We need you to be aware that the Support for Students Growth Center offers multidisciplinary interventions thatdo not fit standard medical procedure codes; therefore, our services are not typically reimbursed by medical insurers. Limitations of Liability and Signature I understand that the Support For Students Growth Center (S.S.G.C.) strives to help as many clients as they can. However, I understand that not all applicants are accepted for services. I understand that the S.S.G.C will use the application information to assess my child’s needs for the purposes of evaluating their abilities and needs and determining placement and service options. Recommendation and approval of my child for services provided by the S.S.G.C is at the discretion of the S.S.G.C administrative team. Refund Policy: All payments, including initial assessments and deposits, are non-refundable. Refunds will not be given for withdrawals or dismissals after a session has begun. If a child engages in conduct which is harmful, dangerous, or extremely disruptive to the overall conduct of the program or the personnel of S.S.G.C., we reserve the right to dismiss the child, and a prorated refund may be offered. Communication with Our Office: Our office provides friendly text reminders of group and individual appointments as a courtesy, so please make sure we have your most recent cell phone number on file. Please note that whether or not you receive a reminder, your child’s group will occur based on the published schedule (we follow the Palm Beach County School District calendar) unless we contact you to cancel or to inform you of a change. Once your child is enrolled in our group program, we encourage you to contact the office with questions or concerns and we will coordinate follow through with their group counselors. You can contact the office at (561) 990-7305. Information on Other Services: Every child is unique in his/her needs and response to interventions. Our groups are designed to facilitate optimal growth for each child; however, generalization of skills will vary. In order to maximize opportunities for each child, partnerships between all parties are crucial. We encourage our families to schedule periodic individual/family appointments and school/teacher consultations. These provide excellent opportunities for everyone involved in your child's “team” to develop skills needed to implement strategies outside of our office, thus helping your child to generalize skills learned in the groups. To assist in this matter, Dr. Nach is available for school or office consultations, individual/family appointments, and school observations/meetings. These service is separate from your child’s Social Skills Programs (and other groups conducted by the S.S.G.C.). I agree to the cost and payment terms agreed upon and understand that these services will likely not be paid for or reimbursed by my insurance company. I agree to hold harmless the S.S.G.C as well as its employees or representatives from any damages or losses of any kind including direct, indirect, incidental, consequential or punitive damages arising out of the applicant’s and/or child’s participation in their programs. I understand that the S.S.G.C makes no warranty or guarantee of any kind whatsoever regarding results or outcomes, whether direct or indirect, from the services it provides. In submitting this application, I certify that the information provided herein, including all enclosed documents, is complete and accurate to the best of my knowledge. I understand that failing to provide complete and accurate information in or with this application will void any potential refunds. I have read the above information - Enter Your Initials below * I am the parent or legal guardian (an individual if over 18) of the child/participant named in this application, and I agree to the terms and conditions outlined above. Online Therapy Consent I understand that I, or my minor child have the following right with respect to teletherapy: 1. I have the right to withhold or withdraw at any time without affecting my right to future care or treatment nor risking loss or withdrawal of any program benefits to which I would otherwise be entitled. 2. The laws that protect the confidentiality of my medical information also apply to teletherapy. As such, I understand that the information disclosed by me during the course of my therapy is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limiting to reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding.” Sign the application by entering your full name in the field below * Please select your form of payment below - If paying by credit card, payment must be made with application submittal. After clicking submit below, you will be taken to the payment page. - If you have chosen to pay by Cash or Check you will need to visit our Boca Raton office to make payment, prior to your first session. - If you have chosen Step Up For Students Scholarship, please contact the office (561-990-7305) with your information after submitting the application. Select Payment Type * Credit Card (We use PayPal, no account is needed) Check or Cash at Boca Office (Receive 5% discount) Step Up For Students Scholarship (Call the office with your information) Coupon Code Paragraph If you are human, leave this field blank. Submit