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Scholar Program Agreement

Date and time
Month
Day
Year
Time
HoursMinutes

Group duration of 2.5hr. 


Ground Rules: 

  • Program fee is due by the 5th of each month.

  • Program fee is due regardless of attendance. 

  • Failure to pay group fee will result in your Rubie not being allowed to attend. Hardship is handled on a case-by-case basis. 

  • Rubie meets at the scheduled time.

  • 30 days discontinuation of service notice is needed. You are still responsible for the full amount of the group fee. 


1.  I am aware that I can choose to discontinue program at any time. 


2. I understand the Scholar Program is designed to facilitate the creation/development of personal, social, and educational goals. 


3. I understand that Scholar Program is a comprehensive process that may involve all areas of my life but does not involve the diagnosis or treatment of mental disorders as defined by the American Psychiatric Association.  I understand that group is not a substitute for counseling, psychotherapy, psychoanalysis, mental health care or substance abuse treatment and I will not use it in place of any form of diagnosis, treatment or therapy. 

 

4. I understand that information will be held confidential unless I state otherwise, in writing, except as required by law. 


5. I do agree for my photos to be taken during group. (If you don’t agree please write below).

Single choice
Yes
No
Other (explain)

I have read and agree with the above.

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If client is under 18 then parent or guardian should sign

Emergency Contact information

Birthday
Month
Day
Year
Multi-line address
1st Emergency Contact
Multi-line address
2nd Emergency Contact
Multi-line address

WITH MY SIGNATURE, I AUTHORIZE THE RELEASE OF THIS INFORMATION ONLY IN CASE OF AN EMERGENCY TO EMS.


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Date
Month
Day
Year

New Client Questions (Youth)

Birthday
Month
Day
Year
Multi-line address

Background Information:

Sibling(s) Name(s) & Age(s)

Ethnic Background

Choose All That Apply

Current Living Situation:

Choose which most closely aligns with you. (N/A = not applicable)

Others living with you:

Select All that Apply

Family/Home Concerns: Parent or sibling illness or mental health concerns; substance use within the family; abuse or safety concerns; parental conflict, divorce, or separation; family or stepparent conflict; feeling unsafe, unsupported, ignored, or disconnected at home; communication difficulties; or other related stressors.

Select All that Apply

Sleep problems:

select all that apply

Eating habits/Weight changes

Multi choice

Social Pressures: Concerns related to popularity or feeling left out; pressure from parents, siblings, or friends; frequent illness; school-related stress; financial concerns; bullying; or other social pressures.


Medical and Mental Health History:

Counseling (current or previous):


Substance Use Support (Current or Previous)


Psychiatric Hospitalization:

Abuse Issues:

Please indicate areas of abuse that you have encountered:  

Physical Abuse     


Multi choice

Sexual Abuse

Multi choice

Verbal Abuse

Multi choice

Emotional Abuse

Multi choice

Social History:

Recreation, hobbies, interests:


Educational Issues:

Academic performance, skipping school, absences, teacher relationships, learning disabilities, or other school-related difficulties.


Religion:

List religious affiliation(s)/spiritual involvement(s):


New Client Questions (Adults)

Birthday
Month
Day
Year
Multi-line address

Background Information:

Sibling(s) Name(s) & Age(s)

Ethnic Background

Choose All That Apply

Current Living Situation:

Choose which most closely aligns with you. (N/A = not applicable)

Others living with you:

Select All that Apply

Family/Home Concerns: Parent or sibling illness or mental health concerns; substance use within the family; abuse or safety concerns; parental conflict, divorce, or separation; family or stepparent conflict; feeling unsafe, unsupported, ignored, or disconnected at home; communication difficulties; or other related stressors.

Select All that Apply

Sleep problems:

select all that apply

Eating habits/Weight changes

Multi choice

Social Pressures: Concerns related to popularity or feeling left out; pressure from parents, siblings, or friends; frequent illness; school-related stress; financial concerns; bullying; or other social pressures.


Medical and Mental Health History:

Counseling (current or previous):


Substance Use Support (Current or Previous)


Psychiatric Hospitalization:

Abuse Issues:

Please indicate areas of abuse that you have encountered:  

Physical Abuse     


Multi choice

Sexual Abuse

Multi choice

Verbal Abuse

Multi choice

Emotional Abuse

Multi choice

Alcohol/Drug Abuse:  

Multi choice

Have there been any undesirable results of your chemical abuse? (low job or school performance,

physical problems, relationship problems, DWI’s?


Single choice
Yes
No

Have you ever been concerned about your own chemical abuse?

Single choice
Yes
No

Have others expressed concern about your chemical abuse?

Single choice
Yes
No

Have others who are close to you abuse alcohol or drugs?

Single choice
Yes
No

Have you ever attended a self-help or support group such as

AA, NA, AlAnon, or ACA?


Single choice
Yes
No

Are you currently attending a self-help or support group?

Single choice
Yes
No

Do you use nicotine? What Kind?

Select all that apply

Social History:

Recreation, hobbies, interests:


Educational Issues:

Academic performance, skipping school, absences, teacher relationships, learning disabilities, or other school-related difficulties. (write n/a if not applicable)


Religion:

List religious affiliation(s)/spiritual involvement(s):


Red Rubies Life Coaching

Wellness Group Agreement

Date and time
Month
Day
Year
Time
HoursMinutes

Ground Rules: 


1. I understand that “Life-skills group” is designed to facilitate the creation/development of personal, social, and mental health well-being. 


2. I understand that “Life-skills group” is a comprehensive process that may involve all areas of my life but does not involve the diagnosis or treatment of mental disorders as defined by the American Psychiatric Association.  I understand that group is not a substitute for counseling, psychotherapy, psychoanalysis, mental health care or substance abuse treatment and I will not use it in place of any form of diagnosis, treatment or therapy. 

 

3. I understand that information will be held confidential unless I state otherwise, in writing, except as required by law. 

5. I do agree for my photos to be taken during group. (If you don’t agree please write below).

Multi choice

I have read and agree with the above.

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

If under 18 years of age then parent/guardian should sign here.

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