Minor Client Forms (Under 18)

Please complete and submit the appropriate forms prior to beginning sessions at A Place To Be

Minor Client Forms (Under 18 Years of Age)

Name *

Name

First Name

Last Name

Gender *

Female

Male

Non-Binary

Preferred Pronouns *

Please select the client's preferred pronouns

Race/Ethnicity

Date of Birth *

Date of Birth

YYYY

Age *

Grade in School *

Name of School Currently Attending *

Parent/Guardian Name(s) *

Parent/Guardian Name(s)

First Name

Last Name

Address *

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary Phone Number *

Primary Phone Number

(###)

###

####

Secondary Phone Number

(###)

###

####

Cell Phone Service Provider

Email Address *

Emergency Contact Information

Emergency Contact 1 Name *

Emergency Contact 1 Name

First Name

Last Name

Relationship to Client

Emergency Contact 1 Phone *

Emergency Contact 1 Phone

(###)

###

####

Emergency Contact 2 Name *

Emergency Contact 2 Name

First Name

Last Name

Relationship to Client *

Emergency Contact 2 Phone *

Emergency Contact 2 Phone

(###)

###

####

What is the minor’s diagnosis/special need/s? *

Extent to which minor is or is not familiar with his/her diagnosis. *

Describe any other health, emotional, or behavioral issues we should be aware of.

Specific areas of difficulty/triggers for the minor.

Past Psychiatric History (Mental Health and Chemical Dependency).

Psychiatric Hospitalizations (Where and When)

Current Presenting Problem (including onset, duration, intensity) *

Please list Other Behavioral Health Specialists, Therapists, or Consultants the minor is currently seeing or recently completed with. Please list their name and occupation.

Allergies/Dietary Restrictions (please list for food, medicines, and environmental). *

Current Medications (please list name, purpose, and dosing frequency)

Additional Information You’d Like Us To Know

WAIVERS AND RELEASES

MINOR RELEASE AND WAIVER OF LIABILITY *

The undersigned parent(s) who has (have) legal custody and/or is (are) the legal guardian(s) of the minor client hereby give permission to his/her participation in the activities and programs of A Place To Be. These activities and programs include individual sessions, group sessions, and programs such as The Same Sky project, Lunch Brunch, and Immersion. In consideration of A Place To Be allowing this participation upon the payment to A Place To Be of any applicable fees for engaging in a specific activity or program, I (we) the undersigned, agree on behalf of our minor, their administrators, executors, heirs and beneficiaries to waive, release, and not to sue A Place To Be, its board of directors, officers, employees (including their representatives and agents), staff and volunteers (all collectively referred to herein as “APTB”) from, against or with respect to all claims, actions, damages, losses and liabilities of any nature related to or arising from any activity, program or event of APTB including but not limited to injury to person and death which are not the result of the sole gross negligence, intentional neglect or willful or wanton conduct by APTB. I (we) further agree on behalf of the client that the client will hold harmless, defend and indemnify APTB from all claims, actions, damages, losses, expenses and liabilities for injuries to the client which are not the result of the sole gross negligence, intentional neglect or willful or wanton conduct by APTB. It is agreed that this release and waiver is final and cannot be changed orally. This release and waiver shall be construed under the laws of the Commonwealth of Virginia.

I acknowledge that I have read and agree to the terms of this waiver

MINOR EMERGENCY MEDICAL TREATMENT RELEASE *

In case of a medical emergency involving the minor client, it is understood that A Place To Be will make reasonable effort to contact the undersigned. If A Place To Be is not able to make timely contact, I (we) hereby authorize an adult representative of A Place To Be to consent to the minor’s x-ray examination, medical, dental, or surgical diagnosis or treatment and physician or hospital care that is advised and supervised by a physician, surgeon, or dentist (as appropriate) who is licensed to practice under the laws of the state in which the medical or dental treatment is rendered. The undersigned agree(s) to pay all costs and expenses incurred in connections with such medical and/or dental services.

I acknowledge that A Place To Be has no medically trained workers on staff (i.e. doctors, nurses, etc.)

I acknowledge that A Place To Be does not provide personal aides, caregivers, or personal attendants. If our child need assistance with personal care, I understand that I must provide that support and let the staff know of the minor client’s needs and the caregiving plan.

MINOR PHOTOGRAPHIC RELEASE *

I (we) agree to permit A Place To Be, hereinafter referred to as “APTB”, to use any photographic or other visual image or voice recording of the client taken or recorded by APTB or by any agent or representative thereof while the client is participating in any APTB activity or program. This use may include the use of photographic, video, or electronic images or voice recordings for education purposes; outreach, advertising and marketing materials; APTB’s website and blogs; social media sites; and APTB archives. It is also agreed that APTB is allowed to so use any original idea, song, creation, recording, picture, artwork or other creative or intellectual property created by the client while participating in any APTB activity or program. I (we), the undersigned, understand substantial rights are given up by signing this agreement and do so freely and without any inducements or assurances. I (we) intend this release and waiver, permissions and authorizations to be enforced to the greatest extent allowed by Virginia law and agree that if any part of this agreement is held to be invalid, the remaining provisions shall remain in full force and effect.

I acknowledge that I have read and agree to the terms of this waiver

I acknowledge that I have read, but do NOT agree to the terms of this waiver

CONFIDENTIALITY AGREEMENT *

To the greatest extent possible, A Place To Be observes and enforces client confidentiality. All information and experiences shared within your sessions will be held confidential to the best of our staff’s professional abilities. We guard your privacy with the utmost importance; however, in compliance with federal, state, and local regulations and our organization’s policies and procedures, confidential information may be revealed under certain circumstances, which may include but is not limited to: Under ethical and legal requirements, we may be required to release information in the event that there is a threat to either your safety or the safety or another person or persons. When there is reasonable suspicion of minor child, elder, or incapacitated adult abuse and/or neglect. Certain legal proceedings may require that information be release when subpoenaed by a judge. If a problem arises collecting payment, it may be necessary to involve a collection agency for purposes of reimbursement. As the client's representative, you may request in writing that information be released to individuals of your choosing. (Please complete our “Permission for Exchange of Information” section below to specify providers.)

I acknowledge that I have read and agree to the terms of this waiver

PERMISSION FOR EXCHANGE OF INFORMATION

I authorize A Place To Be, to share information, (written and/or verbal), with the physicians, case managers, social workers, or with any other personal or professional contact listed below regarding and for the benefit of (type child's name below)

First Name

Last Name

Therapist

First Name

Last Name

Therapist Contact Information

School

Name of School Contact

First Name

Last Name

School Contact Information

Other place/person(s) that information may be shared with

Please list name, contact information, and place of practice.

I acknowledge my consent for information to be exchanged with those listed above

By entering my name below, I certify that I (the parent/guardian of the child client) have read and acknowledged the above waivers and releases and I agree to the terms and conditions therein *

By entering my name below, I certify that I (the parent/guardian of the child client) have read and acknowledged the above waivers and releases and I agree to the terms and conditions therein

First Name

Last Name

FINANCIAL ACCOUNT AND POLICY

Person financially responsible for the account *

Person financially responsible for the account

First Name

Last Name

Relationship to Client *

Home Phone *

Home Phone

(###)

###

####

Cell Phone *

Cell Phone

(###)

###

####

Work Phone

(###)

###

####

Address *

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email Address

Electronic Signature *

Electronic Signature

A Place To Be invoices at the end of each month and payments are due upon receipt. Invoices will be emailed to the address provided above. A Place To Be accepts payments by cash, personal check, and all major credits. Make checks payable to “A Place To Be” and drop it the blue payment box at our 8 North Jay Street location or mail it to P.O. Box 1472, Middleburg, VA 20118. If there is cancellation of a session less than 24 hours before the session begins, a full session payment is expected. I understand that responsibility for payment of services provided by A Place To Be for myself or my dependents is mine, due and payable upon the receipt of invoice/s unless specific financial arrangements have been made. Non-payment of your account could result in a discontinuation of services. If you are experiencing a financial hardship and are unable to pay invoices in full, please contact our accounting department to discuss the matter, (540) 687-6740. We are committed to providing you with the best possible care, and are always happy to discuss our professional fees with you at any time.

First Name

Last Name