Register for Girls Group

Description

The purpose of this group is to focus on equipping young girls to learn more about themselves, and about relating with one another in healthy and positive ways. Sarah and Caroline will be providing opportunities for the girls to reflect, to creatively expresses themselves, to stretch themselves, and to enjoy playing and adventuring outdoors together. During the four group sessions we will not be going towards specific mental or emotional health concerns with individuals in the group, and instead we will focus on the group as a whole and the members having positive connections with each other and learning more about themselves.

Details

When: June 9, 16, 23, and 30*

Group 1: 9:30am- 12:00pm*
Group 2: 1:30pm- 4:00pm*

Meet and greet on Tuesday, May 25, 6-7pm

Where: The Meet and Greet and the June 9 groups will be at the Battlefield office; other locations TBD

For: Girls Ages 11-13

Group Size: 4-6

Led By: Sarah Freeman M.A.MFT and Caroline Ferrari LAPC

Cost: $180 per person for all four groups

Due: May 20 – nonrefundable deposit of $90.

The remaining $90 is due June 1.

*We anticipate filling both groups, but your time slot may not be available. Please indicate your preference at registration and we will try to put you in if there is space.

Step 1 of 4

Name*
Girl's First Name Girl's First Name
Child's Date of Birth
MM slash DD slash YYYY
Please choose which group you prefer*
- Group 1: 9:30am- 12:00pm
- Group 2: 1:30pm- 4:00pm
(Space is limited. We will try to place you in the time slot selected.)
Availability:*
- I can only attend in the time slot selected
- I can attend in either time slot
Parent/ Guardian*
First Name Last Name
(Please list the person who is completing this registration form.)
Parent's Email*
Parent's Phone*
Emergency Contact Information
Please list the parent/guardian's emergency contact information
Where does the parent work?
Work Phone
Other Phone
(Please list any other phone number not listed above.)

INFORMED CONSENT FOR OUTDOOR THERAPY

This document contains important information about the decision (yours and your therapist’s) to begin therapy sessions outdoors in light of the COVID-19 crisis. It is a supplement to the general informed consent that we agreed to at the outset of our clinical work together. Outdoor psychotherapy may take several forms. It may involve sitting outdoors on a bench/chair outside of our offices or sitting in a public place such as a park pavilion. It may also take the form of walking while addressing therapeutic goals and topics. If you decide to walk, some of the activities you might participate in include walking on sidewalks/bike paths and/or exploring public parks and open spaces.

COVID-19 Specific Information: The decision about whether to engage in outdoor therapy is based on current conditions and guidelines which may change at any time. It is possible that a return to remote services will be necessary at some point based on health and safety considerations. This decision will be made in consultation with you, but your therapist’s will make the final determination based on a careful weighing of the risks and applicable regulations.
In order to engage in outdoor therapy, the following protocols must be followed by clients and providers:
- You agree to take certain precautions which will help keep everyone safer from exposure, sickness and possible death.
- You agree to only keep your in-person appointment if you are free of COVID-19 symptoms.
- You agree that if you have been exposed to another person who is showing signs of infection or is confirmed to have COVID-19 within the last two weeks you will not come to the group session.
- You agree to use alcohol-based hand sanitizer when you begin your outdoor session.
- If a resident of your home tests positive for the infection, you will immediately inform your therapist and/or our staff.
We may change the above precautions if additional local, state or federal orders or guidelines are published. If that happens, we will talk about any necessary changes.
In addition, please be aware that we may become legally required at some point to disclose that you and your therapist have been in contact, especially if either you or your therapist were to test positive or show signs of COVID-19 infection. If we are legally compelled to disclose information, we will inform you and will only provide the minimum necessary information (e.g., your name, contact information, and the dates of contact) required by law. By signing this form, you are agreeing that we may fulfill our legal obligations to report without an additional signed release.
Additional Considerations:
There are possible risks of outdoor therapy, including, but not limited to:
- Accidental injuries from tripping or falling while walking, or potentially being struck by a bicyclist or a car.
- My participation in water activities, such as Kayaking, and/or use of such equipment may result in injury or illness including, but not limited to bodily injury, disease, strains, fractures, partial and/or total paralysis, death or other ailments that could cause serious disability.
- Physical dangers including insect stings, animal bites, falling branches or sticks, sunburn, exposure to heat/cold, and similar risks.
- Adverse weather conditions including heat, rain, and storms. Please note that when rain or storms are forecast, it may be necessary to change the venue of the group session.
- Confidentiality issues: complete confidentiality cannot be guaranteed. Though every attempt will be made to not engage in private conversations when others are in close proximity, it is not possible to guarantee that conversations will not be heard by others.
- Coming into contact with someone the therapist or client knows. If the therapist comes into contact with a known person, therapist will not disclose that you are a client or any other confidential information. If you come into contact with a known person, therapist will not initiate interaction with that person but will follow your lead in guiding any interactions.
- Given the prevalence of cellphones, it is also possible that you may be photographed or videoed with your therapist without your knowledge and that you and your therapist would have no control over the dissemination of those photos/videos.
Consent and Agreements
In order to engage in outdoor therapy, you understand and agree to the following:
- You understand that participation in outdoor therapy is completely voluntary.
- You agree to obtain approval from your doctor before engaging in outdoor therapy if you have any medical condition that could affect your ability to participate in this activity and to disclose those conditions or limitations to your therapist.
- You agree to take full responsibility for your physical safety and to not engage in any activity in which you do not feel safe.
- You agree to let your therapist know immediately if you become physically or emotionally uncomfortable during a session.
- You agree to abide by all COVID-19 protocols noted above.
By signing below, you indicate that you understand and accept the risks of outdoor therapy, including potential risk of exposure to COVID-19, and nevertheless consent to outdoor therapy under the conditions outlined above. This consent can be withdrawn in writing at any time.
Parent's Signature*
Child's Signature
Date
MM slash DD slash YYYY

Serving, Since 1996

Since 1996, we've been providing Christ-centered, Biblically-based counseling services in Rome and Cartersville, GA. We covet your prayers and we are always appreciative of new and ongoing financial supporters.

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Phone: 706-235-9350

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Fax: 706-936-1955

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Rome GA Office

5 E 6th Ave
Rome, GA 30161

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Cartersville GA Office

650 Henderson Drive #435
Cartersville, GA 30120

Register for Girls Group

Description

Details

Step 1 of 4

Emergency Contact Information

Emergency Contact- Other Parent

Emergency Contact Information- Other

INFORMED CONSENT FOR OUTDOOR THERAPY

Serving, Since 1996

Phone: 706-235-9350

Fax: 706-936-1955

Rome GA Office

Cartersville GA Office