Group Participant Intake Form Please complete this form to join one of Light On Anxiety's treatment groups. Participant Legal Name* First Last Participant Preferred Name Participant Preferred PronounsPronouns are used to refer to someone in the third person. We want to know how to respectfully refer to you. Examples: he, him, his she, her, hers they, them, theirs Participant Date of Birth* Month Day Year Email Used for Communication* Phone Used for Communication*Parent / Legal Guardian Name* First Last Parent / Legal Guardian Phone*Parent / Legal Guardian Email* Which Light On Anxiety treatment group are you joining?* What are your/the participant's goals for attending this group?*How has anxiety impacted you/the participant or stood in the way of your/their goals?*Emergency Contact InformationEmergency Contact Name* First Last Emergency Contact Phone Number*To join a group with Light On Anxiety, it is required that you complete a release of information for your emergency contact. Note: To ensure progress on intake form is not lost, right click on the link to open the release of information in a new tab/window.Release of Information for Emergency Contact* I certify that in the case that Light On Anxiety determines I am a harm to myself or to others, Light On Anxiety has permission to coordinate care on my behalf with my emergency contact. I further certify that I have completed a release of information for my/the client's emergency contact or that I will submit a Release of Information for Emergency Contact within 24 hours of my/the client's first group appointment with Light On Anxiety.Acknowledgement of Group Treatment Confidentiality Policy* I understand and agree to Light On anxiety's Group Treatment Treatment Confidentiality PolicyYou have the right to confidentiality and privacy when attending a Light On Anxiety treatment group. Confidentiality within the group setting is a shared responsibility of all members and leaders. While group leaders may not disclose any client communications or information except as provided by law, group members' communications are not protected. As such, confidentiality within the group setting is often based on mutual trust and respect. It is expected that all Light On Anxiety treatment group members refrain from disclosing any information shared by other group members.Consent to Treatment* I consent to treatment. I certify receipt and understanding of Light On Anxiety's informed consent and agree to all its terms and conditions.Date* MM slash DD slash YYYY Print Name of Patient / Parent / Legal Guardian* Signature of Participant / Parent / Legal Guardian - Consent to Treatment*By signing this form, I consent to treatment. I certify that I have read Light On Anxiety's Informed Consent and understand and agree to abide by all its terms.
