Please answer the following questions to the best of your ability. These questions are to help the clinical and educational team of the S.S.G.C and College Life Skills Program (a subsidiary program of the S.S.G.C.) provide the best service possible. This information is considered private and confidential. (Parents answer with or for minor children)
Who else can pick up child other than parents (name/phone/relation)
General Health and Mental Health Information (parents answer with or for minor children)
Social and Behavioral Information
(Parents answer with or for minor children)
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.
I understand that a consultation with Dr. Eric Nach, myself and family member(s) will take between one (1) and one and a half (1.5) hours at the rate of four hundred dollars ($400) per hour, which health insurance will not typically cover. This fee includes; a phone, virtual or in person meeting with parent(s), potential client, other participants the family chooses to have attend and Dr. Eric Nach, a review of all submitted documents/assessments and a “functional assessment” of findings and discussion of proposed services in writing that may be considered by the family, all included.
Confirm by checking box
Limitations of Liability and Signature
I understand that the Support For Students Growth Center (S.S.G.C.), including the College Life Skills Program (a subsidiary program of the 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 (or self if over 18 years of age) for the purposes of evaluating their abilities and needs and determining placement and service options. Recommendation and approval of potential client for services provided by the S.S.G.C is at the discretion of the S.S.G.C administrative team.
Group Attendance: All of our therapeutic groups rely on clients’s regular attendance for all members to make optimal progress. It affects the whole group whenever a participant is absent, so please try to be as consistent as possible. Please keep in mind that we are reserving the cleints spot in group and are staffing and adjusting our curriculum accordingly, whether he/she is able to make it or not.
Families will not be issued a refund or credit for any missed group dates*.
If the client misses group, we will provide a brief review of the material covered during the following group session. Additionally, we are happy to send you the “Weekly Topic Summary” for the session that was missed so that you may review it with your child.
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 client 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, the client’s group/session will occur based on the published schedule (we follow the Palm Beach County School District calendar) or individual schedule arranged with parent or client, unless we contact you to cancel or to inform you of a change. Once the client is enrolled in any of our services or programs, we encourage you to contact the office with questions or concerns and we will coordinate follow through with their counselors, therapist or other S.S.G.C. staff. You can contact the office at (561) 990-7305.
Information on Other Services: Every client is unique in his/her needs and response to interventions. Our groups and all our services are designed to facilitate optimal growth for each client; however, generalization of skills will vary. In order to maximize opportunities for each client, partnerships between all parties are crucial. We encourage our families to schedule periodic individual/family appointments and school/teacher consultations with Dr. Nach to evaluate the clients progress and rightness of fit. These provide excellent opportunities for everyone involved in the clients “team” to develop skills needed to implement strategies outside of our direct services, thus helping your “child” to generalize skills learned in the groups and individualized services. To assist in this matter, Dr. Nach is available for school or office consultations, individual/family appointments, and school observations/meetings. These services maybe separate and incur additional cost, from the client’s typical services 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 any insurance coverage. 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 potential client’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 of the child/participant named in this application, and I agree to the terms and conditions outlined above.
I am the adult (18 years of age or older) participant named in this application, and I agree to the terms and conditions outlined above.