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)
Last
First
Middle
Last
First
Current Address
Street
Apt., PO Box, Suite
City
State
Zip/Postal

Who else can pick up child other than parents (name/phone/relation)

Name
Phone
Relation
Name
Phone
Relation

General Health and Mental Health Information (parents answer with or for minor children)

Number of Days
Minutes / Hours

School Information

Family Information

Social and Behavioral Information
(Parents answer with or for minor children)

Behavior and Emotionality Therapy, Counseling and Training Packages

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Insurance Information

We need you to be aware that the Support for Students Growth Center offers multidisciplinary interventions that
do not fit standard medical procedure codes; therefore, our services are not typically reimbursed by medical insurers.

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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 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.”

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.
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