{"id":1078,"date":"2023-04-16T16:45:11","date_gmt":"2023-04-16T23:45:11","guid":{"rendered":"https:\/\/thechildandfamilyconnection.com\/?page_id=1078"},"modified":"2023-04-18T20:02:12","modified_gmt":"2023-04-19T03:02:12","slug":"forms","status":"publish","type":"page","link":"https:\/\/thechildandfamilyconnection.com\/social-skills-groups\/forms\/","title":{"rendered":"Forms"},"content":{"rendered":"\n\n\t\t\t<h1>Parenting is the hardest job you&#8217;ll ever have.<\/h1>\t\t\t\n\t\t\t<h3>Social Skills Groups Client Forms<\/h3>\t\t\t\n\t\t\t\t\t\t<h5 tabindex=\"0\">Child Intake Form<\/h5>\n\t\t\t<script type=\"text\/javascript\">if(!gform){document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0});var gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),null==t&&(t=10),gform.hooks[o][n].push({tag:i,callable:r,priority:t})},doHook:function(o,n,r){if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[o][n]){var t,i=gform.hooks[o][n];i.sort(function(o,n){return o.priority-n.priority});for(var e=0;e<i.length;e++)\"function\"!=typeof(t=i[e].callable)&&(t=window[t]),\"action\"==o?t.apply(null,r):r[0]=t.apply(null,r)}if(\"filter\"==o)return r[0]},removeHook:function(o,n,r,t){if(null!=gform.hooks[o][n])for(var i=gform.hooks[o][n],e=i.length-1;0<=e;e--)null!=t&&t!=i[e].tag||null!=r&&r!=i[e].priority||i.splice(e,1)}}}<\/script>\n                <div class='gf_browser_unknown gform_wrapper gform_legacy_markup_wrapper' id='gform_wrapper_23' style='display:none'><div id='gf_23' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_23' id='gform_23'  action='\/wp-json\/wp\/v2\/pages\/1078#gf_23' > \r\n <input type='hidden' class='gforms-pum' value='{\"closepopup\":false,\"closedelay\":0,\"openpopup\":false,\"openpopup_id\":0}' \/>\n                        <div class='gform_body gform-body'><ul id='gform_fields_23' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_23_196\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_23_196' >Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_196' id='input_23_196' type='text' value='' class='large' tabindex='1'    aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_23_1\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h2 class=\"gsection_title\">Child Demographics<\/h2><\/li><li id=\"field_23_2\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Child Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_23_2'>\n                            \n                            <span id='input_23_2_3_container' class='name_first' >\n                                                    <input type='text' name='input_2.3' id='input_23_2_3' value='' aria-label='First name' tabindex='3'  aria-required='true'     \/>\n                                                    <label for='input_23_2_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_23_2_6_container' class='name_last' >\n                                                    <input type='text' name='input_2.6' id='input_23_2_6' value='' aria-label='Last name' tabindex='5'  aria-required='true'     \/>\n                                                    <label for='input_23_2_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_23_8\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_23_8' >Date of Birth:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_8' id='input_23_8' type='text' value='' class='datepicker mdy datepicker_with_icon gdatepicker_with_icon' tabindex='7'  placeholder='mm\/dd\/yyyy' aria-describedby=\"input_23_8_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_23_8_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_23_8' class='gform_hidden' value='https:\/\/thechildandfamilyconnection.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_23_197\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_23_197' >Age<\/label><div class='ginput_container ginput_container_number'><input name='input_197' id='input_23_197' type='text'    value='' class='small' tabindex='8'     aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_23_3\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_23_3' >Gender:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_23_3' type='text' value='' class='medium'   tabindex='9'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_23_4\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_23_4' >Race:<\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_23_4' type='text' value='' class='medium'   tabindex='10'   aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_23_198\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_23_198' >Name of School:<\/label><div class='ginput_container ginput_container_text'><input name='input_198' id='input_23_198' type='text' value='' class='large'   tabindex='11'   aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_23_199\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_23_199' >Grade Level:<\/label><div class='ginput_container ginput_container_text'><input name='input_199' id='input_23_199' type='text' value='' class='large'   tabindex='12'   aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_23_5\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Home Address:<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address' id='input_23_5' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1' id='input_23_5_1_container' >\n                                        <input type='text' name='input_5.1' id='input_23_5_1' value='' tabindex='13'   aria-required='false'    \/>\n                                        <label for='input_23_5_1' id='input_23_5_1_label' >Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2' id='input_23_5_2_container' >\n                                        <input type='text' name='input_5.2' id='input_23_5_2' value='' tabindex='14'    aria-required='false'   \/>\n                                        <label for='input_23_5_2' id='input_23_5_2_label' >Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city' id='input_23_5_3_container' >\n                                    <input type='text' name='input_5.3' id='input_23_5_3' value='' tabindex='15'   aria-required='false'    \/>\n                                    <label for='input_23_5_3' id='input_23_5_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state' id='input_23_5_4_container' >\n                                        <input type='text' name='input_5.4' id='input_23_5_4' value='' tabindex='17'     aria-required='false'    \/>\n                                        <label for='input_23_5_4' id='input_23_5_4_label' >State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip' id='input_23_5_5_container' >\n                                    <input type='text' name='input_5.5' id='input_23_5_5' value='' tabindex='18'   aria-required='false'    \/>\n                                    <label for='input_23_5_5' id='input_23_5_5_label' >ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country' id='input_23_5_6_container' >\n                                        <select name='input_5.6' id='input_23_5_6' tabindex='19'  aria-required='false'    ><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cape Verde' >Cape Verde<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Congo, Republic of the' >Congo, Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czech Republic' >Czech Republic<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini (Swaziland)' >Eswatini (Swaziland)<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard and McDonald Islands' >Heard and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macau' >Macau<\/option><option value='Macedonia' >Macedonia<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Korea' >North Korea<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russia' >Russia<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena' >Saint Helena<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia' >South Georgia<\/option><option value='South Korea' >South Korea<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen Islands' >Svalbard and Jan Mayen Islands<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria' >Syria<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania' >Tanzania<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkey' >Turkey<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_23_5_6' id='input_23_5_6_label' >Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_23_200\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Is Child a client (currently receiving services) with The Child &amp; Family Connection?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_200'>\n\t\t\t<li class='gchoice gchoice_23_200_0'>\n\t\t\t\t<input name='input_200' type='radio' value='Yes'  id='choice_23_200_0' tabindex='20'   \/>\n\t\t\t\t<label for='choice_23_200_0' id='label_23_200_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_200_1'>\n\t\t\t\t<input name='input_200' type='radio' value='No'  id='choice_23_200_1' tabindex='21'   \/>\n\t\t\t\t<label for='choice_23_200_1' id='label_23_200_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_190\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >If YES, please indicate who your Child&#039;s Therapist is below:<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_190'>\n\t\t\t<li class='gchoice gchoice_23_190_0'>\n\t\t\t\t<input name='input_190' type='radio' value='Dr. Hayley Pedersen'  id='choice_23_190_0' tabindex='22'   \/>\n\t\t\t\t<label for='choice_23_190_0' id='label_23_190_0'>Dr. Hayley Pedersen<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_190_1'>\n\t\t\t\t<input name='input_190' type='radio' value='Claire Sfregola'  id='choice_23_190_1' tabindex='23'   \/>\n\t\t\t\t<label for='choice_23_190_1' id='label_23_190_1'>Claire Sfregola<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_190_2'>\n\t\t\t\t<input name='input_190' type='radio' value='Dr. Courtney Knapp'  id='choice_23_190_2' tabindex='24'   \/>\n\t\t\t\t<label for='choice_23_190_2' id='label_23_190_2'>Dr. Courtney Knapp<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_190_3'>\n\t\t\t\t<input name='input_190' type='radio' value='Dr. Brooke Herd'  id='choice_23_190_3' tabindex='25'   \/>\n\t\t\t\t<label for='choice_23_190_3' id='label_23_190_3'>Dr. Brooke Herd<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_190_4'>\n\t\t\t\t<input name='input_190' type='radio' value='Bee-Yu (Ariel) Yung'  id='choice_23_190_4' tabindex='26'   \/>\n\t\t\t\t<label for='choice_23_190_4' id='label_23_190_4'>Bee-Yu (Ariel) Yung<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_201\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_23_201' >Please provide a brief description of the reason(s) why your Child is currently being seen at TCFC (i.e.: depression, anxiety, ADHD, loss\/grief issues, parental divorce, separation, parenting issues, other behavioral\/emotional issues, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_201' id='input_23_201' class='textarea small' tabindex='27'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_23_202\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h2 class=\"gsection_title\">Parent Information\/Family Background<\/h2><\/li><li id=\"field_23_203\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Parent Name (Parent 1)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_23_203'>\n                            \n                            <span id='input_23_203_3_container' class='name_first' >\n                                                    <input type='text' name='input_203.3' id='input_23_203_3' value='' aria-label='First name' tabindex='29'  aria-required='true'     \/>\n                                                    <label for='input_23_203_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_23_203_6_container' class='name_last' >\n                                                    <input type='text' name='input_203.6' id='input_23_203_6' value='' aria-label='Last name' tabindex='31'  aria-required='true'     \/>\n                                                    <label for='input_23_203_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_23_204\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_23_204' >Phone (Parent 1):<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_204' id='input_23_204' type='text' value='' class='large' tabindex='33'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_23_11\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_23_11' >Email (Parent 1):<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_11' id='input_23_11' type='text' value='' class='medium' tabindex='34'    aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_23_19\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_23_19' >Occupation\/Employer\/Title (Parent 1):<\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_23_19' type='text' value='' class='medium'   tabindex='35'   aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_23_20\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Parent Name (Parent 2):<\/label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_23_20'>\n                            \n                            <span id='input_23_20_3_container' class='name_first' >\n                                                    <input type='text' name='input_20.3' id='input_23_20_3' value='' aria-label='First name' tabindex='37'  aria-required='false'     \/>\n                                                    <label for='input_23_20_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_23_20_6_container' class='name_last' >\n                                                    <input type='text' name='input_20.6' id='input_23_20_6' value='' aria-label='Last name' tabindex='39'  aria-required='false'     \/>\n                                                    <label for='input_23_20_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_23_21\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_23_21' >Phone Number (Parent 2):<\/label><div class='ginput_container ginput_container_phone'><input name='input_21' id='input_23_21' type='text' value='' class='medium' tabindex='41'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_23_22\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_23_22' >Email (Parent 2):<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_22' id='input_23_22' type='text' value='' class='medium' tabindex='42'    aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_23_24\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_23_24' >Occupation\/Employer\/Title (Parent 2):<\/label><div class='ginput_container ginput_container_text'><input name='input_24' id='input_23_24' type='text' value='' class='medium'   tabindex='43'   aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_23_205\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Parents&#039; Current Marital Status:<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_205'>\n\t\t\t<li class='gchoice gchoice_23_205_0'>\n\t\t\t\t<input name='input_205' type='radio' value='Unmarried\/Never Married'  id='choice_23_205_0' tabindex='44'   \/>\n\t\t\t\t<label for='choice_23_205_0' id='label_23_205_0'>Unmarried\/Never Married<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_205_1'>\n\t\t\t\t<input name='input_205' type='radio' value='Married (to each other)'  id='choice_23_205_1' tabindex='45'   \/>\n\t\t\t\t<label for='choice_23_205_1' id='label_23_205_1'>Married (to each other)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_205_2'>\n\t\t\t\t<input name='input_205' type='radio' value='Separated (please note years below)'  id='choice_23_205_2' tabindex='46'   \/>\n\t\t\t\t<label for='choice_23_205_2' id='label_23_205_2'>Separated (please note years below)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_205_3'>\n\t\t\t\t<input name='input_205' type='radio' value='Divorced (please note years below)'  id='choice_23_205_3' tabindex='47'   \/>\n\t\t\t\t<label for='choice_23_205_3' id='label_23_205_3'>Divorced (please note years below)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_205_4'>\n\t\t\t\t<input name='input_205' type='radio' value='Widowed (please indicate deceased parent&#039;s age\/year)'  id='choice_23_205_4' tabindex='48'   \/>\n\t\t\t\t<label for='choice_23_205_4' id='label_23_205_4'>Widowed (please indicate deceased parent's age\/year)<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_206\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_23_206' >Please include any additional information regarding parents&#039; current marital status below (i.e.: years separated\/divorced\/widowed, remarried\/involved in another relationship, etc.):<\/label><div class='ginput_container ginput_container_text'><input name='input_206' id='input_23_206' type='text' value='' class='large'   tabindex='49'   aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_23_207\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Is Child Adopted?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_207'>\n\t\t\t<li class='gchoice gchoice_23_207_0'>\n\t\t\t\t<input name='input_207' type='radio' value='Yes'  id='choice_23_207_0' tabindex='50'   \/>\n\t\t\t\t<label for='choice_23_207_0' id='label_23_207_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_207_1'>\n\t\t\t\t<input name='input_207' type='radio' value='No'  id='choice_23_207_1' tabindex='51'   \/>\n\t\t\t\t<label for='choice_23_207_1' id='label_23_207_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_208\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_23_208' >Who is the Child&#039;s Legal Guardian(s)?<\/label><div class='ginput_container ginput_container_text'><input name='input_208' id='input_23_208' type='text' value='' class='large'   tabindex='52'   aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_23_209\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Who does Child currently live with?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_209'>\n\t\t\t<li class='gchoice gchoice_23_209_0'>\n\t\t\t\t<input name='input_209' type='radio' value='Parent 1 Only'  id='choice_23_209_0' tabindex='53'   \/>\n\t\t\t\t<label for='choice_23_209_0' id='label_23_209_0'>Parent 1 Only<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_209_1'>\n\t\t\t\t<input name='input_209' type='radio' value='Parent 2 Only'  id='choice_23_209_1' tabindex='54'   \/>\n\t\t\t\t<label for='choice_23_209_1' id='label_23_209_1'>Parent 2 Only<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_209_2'>\n\t\t\t\t<input name='input_209' type='radio' value='Both Parents (Together)'  id='choice_23_209_2' tabindex='55'   \/>\n\t\t\t\t<label for='choice_23_209_2' id='label_23_209_2'>Both Parents (Together)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_209_3'>\n\t\t\t\t<input name='input_209' type='radio' value='Both Parents (Separately, Part-Time, Shared Custody)'  id='choice_23_209_3' tabindex='56'   \/>\n\t\t\t\t<label for='choice_23_209_3' id='label_23_209_3'>Both Parents (Separately, Part-Time, Shared Custody)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_209_4'>\n\t\t\t\t<input name='input_209' type='radio' value='gf_other_choice'  id='choice_23_209_4' tabindex='57'  onfocus=\"jQuery(this).next('input').focus();\" \/>\n\t\t\t\t<input class='small' id='input_23_209_other' name='input_209_other' type='text' value='Other' aria-label='Other' onfocus='jQuery(this).prev(\"input\")[0].click(); if(jQuery(this).val() == \"Other\") { jQuery(this).val(\"\"); }' onblur='if(jQuery(this).val().replace(\" \", \"\") == \"\") { jQuery(this).val(\"Other\"); }' tabindex='57'  \/>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_210\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_23_210' >Please include any additional information regarding Child&#039;s current living situation (i.e.: split\/shared custody, living with other family members, etc.)<\/label><div class='ginput_container ginput_container_text'><input name='input_210' id='input_23_210' type='text' value='' class='large'   tabindex='58'   aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_23_211\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_23_211' >List ALL persons currently living in household with Child (i.e.: name, gender, age, relationship to child):<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_211' id='input_23_211' class='textarea small' tabindex='59'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_23_212\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h2 class=\"gsection_title\">Child Medical Information\/History<\/h2><\/li><li id=\"field_23_213\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Does your Child have any MENTAL HEALTH Diagnoses that I need to be aware of (i.e.: Depression, Anxiety, ADHD, Autism, Schizophrenia, etc.)?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_213'>\n\t\t\t<li class='gchoice gchoice_23_213_0'>\n\t\t\t\t<input name='input_213' type='radio' value='Yes (please specify below)'  id='choice_23_213_0' tabindex='60'   \/>\n\t\t\t\t<label for='choice_23_213_0' id='label_23_213_0'>Yes (please specify below)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_213_1'>\n\t\t\t\t<input name='input_213' type='radio' value='No'  id='choice_23_213_1' tabindex='61'   \/>\n\t\t\t\t<label for='choice_23_213_1' id='label_23_213_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_214\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_23_214' >Please indicate any additional information regarding your child&#039;s MENTAL HEALTH diagnosis (i.e.: name of diagnoses, year diagnosed\/diagnosed by who, etc.)<\/label><div class='ginput_container ginput_container_text'><input name='input_214' id='input_23_214' type='text' value='' class='large'   tabindex='62'   aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_23_215\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Does your Child have any MEDICAL Diagnoses\/Conditions that I need to be aware of?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_215'>\n\t\t\t<li class='gchoice gchoice_23_215_0'>\n\t\t\t\t<input name='input_215' type='radio' value='Yes (please specify below)'  id='choice_23_215_0' tabindex='63'   \/>\n\t\t\t\t<label for='choice_23_215_0' id='label_23_215_0'>Yes (please specify below)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_215_1'>\n\t\t\t\t<input name='input_215' type='radio' value='No'  id='choice_23_215_1' tabindex='64'   \/>\n\t\t\t\t<label for='choice_23_215_1' id='label_23_215_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_216\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_23_216' >Please indicate any additional information regarding your child&#039;s MEDICAL diagnosis (i.e.: name of diagnoses, year diagnosed\/diagnosed by who, etc.)<\/label><div class='ginput_container ginput_container_text'><input name='input_216' id='input_23_216' type='text' value='' class='large'   tabindex='65'   aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_23_217\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Does your Child currently take any prescription MEDICATION(S) that I need to be aware of?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_217'>\n\t\t\t<li class='gchoice gchoice_23_217_0'>\n\t\t\t\t<input name='input_217' type='radio' value='Yes (please specify below)'  id='choice_23_217_0' tabindex='66'   \/>\n\t\t\t\t<label for='choice_23_217_0' id='label_23_217_0'>Yes (please specify below)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_217_1'>\n\t\t\t\t<input name='input_217' type='radio' value='No'  id='choice_23_217_1' tabindex='67'   \/>\n\t\t\t\t<label for='choice_23_217_1' id='label_23_217_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_218\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_23_218' >Please indicate any additional information regarding the MEDICATION(S) that your child is taking (i.e.: drug name, dosage, purpose\/condition, etc.)<\/label><div class='ginput_container ginput_container_text'><input name='input_218' id='input_23_218' type='text' value='' class='large'   tabindex='68'   aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_23_219\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_23_219' >Please indicate any known ALLERGIES your Child has that I need to be aware of:<\/label><div class='ginput_container ginput_container_text'><input name='input_219' id='input_23_219' type='text' value='' class='large'   tabindex='69'   aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_23_220\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label'  >Does your child currently have an Individualized Educational Plan (IEP) or 504 Plan in place at School?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_23_220'>\n\t\t\t<li class='gchoice gchoice_23_220_0'>\n\t\t\t\t<input name='input_220' type='radio' value='Yes (please specify below)'  id='choice_23_220_0' tabindex='70'   \/>\n\t\t\t\t<label for='choice_23_220_0' id='label_23_220_0'>Yes (please specify below)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_23_220_1'>\n\t\t\t\t<input name='input_220' type='radio' value='No'  id='choice_23_220_1' tabindex='71'   \/>\n\t\t\t\t<label for='choice_23_220_1' id='label_23_220_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_221\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_23_221' >Please include any additional information regarding your child&#039;s IEP\/504 Plan (i.e.: qualifying condition, placement, IEP goals, types of services\/accommodations child is receiving at school, currently in the process of being assessed for an IEP, etc.)<\/label><div class='ginput_container ginput_container_text'><input name='input_221' id='input_23_221' type='text' value='' class='large'   tabindex='72'   aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_23_35\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h2 class=\"gsection_title\">Presenting Problem:<\/h2><\/li><li id=\"field_23_223\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label gfield_label_before_complex'  >Please indicate the behavioral\/emotional\/social concerns you have for your Child (check all that applies):<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_23_223'><li class='gchoice gchoice_23_223_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.1' type='checkbox'  value='No Friends\/Lack of Friends'  id='choice_23_223_1' tabindex='73'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_223_1' id='label_23_223_1'>No Friends\/Lack of Friends<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_223_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.2' type='checkbox'  value='No Interest in Engaging\/Playing with Others'  id='choice_23_223_2' tabindex='74'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_223_2' id='label_23_223_2'>No Interest in Engaging\/Playing with Others<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_223_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.3' type='checkbox'  value='Difficulty Playing Cooperatively with Peers (i.e.: sore loser, sharing\/taking turns, waiting, having patience, etc.)'  id='choice_23_223_3' tabindex='75'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_223_3' id='label_23_223_3'>Difficulty Playing Cooperatively with Peers (i.e.: sore loser, sharing\/taking turns, waiting, having patience, etc.)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_223_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.4' type='checkbox'  value='Attention Problems (i.e.: easily distracted, trouble staying focused\/on task, disorganized, easily forgetful, etc.)'  id='choice_23_223_4' tabindex='76'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_223_4' id='label_23_223_4'>Attention Problems (i.e.: easily distracted, trouble staying focused\/on task, disorganized, easily forgetful, etc.)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_223_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.5' type='checkbox'  value='Bossy\/Dominating\/Controlling Towards Peers'  id='choice_23_223_5' tabindex='77'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_223_5' id='label_23_223_5'>Bossy\/Dominating\/Controlling Towards Peers<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_223_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.6' type='checkbox'  value='Isolates Self\/Withdraws'  id='choice_23_223_6' tabindex='78'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_223_6' id='label_23_223_6'>Isolates Self\/Withdraws<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_223_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.7' type='checkbox'  value='Overly Shy\/Timid\/Anxious'  id='choice_23_223_7' tabindex='79'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_223_7' id='label_23_223_7'>Overly Shy\/Timid\/Anxious<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_223_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.8' type='checkbox'  value='Chronic Lying'  id='choice_23_223_8' tabindex='80'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_223_8' id='label_23_223_8'>Chronic Lying<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_223_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.9' type='checkbox'  value='Hyperactivity\/Restlessness'  id='choice_23_223_9' tabindex='81'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_223_9' id='label_23_223_9'>Hyperactivity\/Restlessness<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_223_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.11' type='checkbox'  value='Trouble Making\/Keeping Friends'  id='choice_23_223_11' tabindex='82'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_223_11' id='label_23_223_11'>Trouble Making\/Keeping Friends<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_223_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.12' type='checkbox'  value='Lack of Empathy\/Remorse'  id='choice_23_223_12' tabindex='83'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_223_12' id='label_23_223_12'>Lack of Empathy\/Remorse<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_223_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.13' type='checkbox'  value='Engages\/Plays Too Roughly with Others'  id='choice_23_223_13' tabindex='84'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_223_13' id='label_23_223_13'>Engages\/Plays Too Roughly with Others<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_223_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.14' type='checkbox'  value='Lack of Personal Space\/Boundaries'  id='choice_23_223_14' tabindex='85'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_223_14' id='label_23_223_14'>Lack of Personal Space\/Boundaries<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_223_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.15' type='checkbox'  value='Struggles to Read Social Cues Appropriately'  id='choice_23_223_15' tabindex='86'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_223_15' id='label_23_223_15'>Struggles to Read Social Cues Appropriately<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_223_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.16' type='checkbox'  value='Difficulty with Listening\/Following Directions'  id='choice_23_223_16' tabindex='87'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_223_16' id='label_23_223_16'>Difficulty with Listening\/Following Directions<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_223_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.17' type='checkbox'  value='Poor Emotional Dysregulation'  id='choice_23_223_17' tabindex='88'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_223_17' id='label_23_223_17'>Poor Emotional Dysregulation<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_223_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.18' type='checkbox'  value='Poor Coping Skills'  id='choice_23_223_18' tabindex='89'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_223_18' id='label_23_223_18'>Poor Coping Skills<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_223_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.19' type='checkbox'  value='Frequent Tantrums\/Meltdowns\/Outbursts'  id='choice_23_223_19' tabindex='90'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_223_19' id='label_23_223_19'>Frequent Tantrums\/Meltdowns\/Outbursts<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_223_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.21' type='checkbox'  value='Frequent Verbal Outbursts\/Interrupts Others'  id='choice_23_223_21' tabindex='91'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_223_21' id='label_23_223_21'>Frequent Verbal Outbursts\/Interrupts Others<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_223_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.22' type='checkbox'  value='Gets Mad\/Upset EasilyLow Frustration Tolerance'  id='choice_23_223_22' tabindex='92'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_223_22' id='label_23_223_22'>Gets Mad\/Upset EasilyLow Frustration Tolerance<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_223_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.23' type='checkbox'  value='Gives Up Easily\/Shuts Down'  id='choice_23_223_23' tabindex='93'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_223_23' id='label_23_223_23'>Gives Up Easily\/Shuts Down<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_223_24'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.24' type='checkbox'  value='Verbal Aggression Towards Others (i.e.: uses curse words, makes mean\/hurtful comments, etc.)'  id='choice_23_223_24' tabindex='94'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_223_24' id='label_23_223_24'>Verbal Aggression Towards Others (i.e.: uses curse words, makes mean\/hurtful comments, etc.)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_223_25'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.25' type='checkbox'  value='Physical Aggression Towards Others (i.e.: hitting, kicking, biting, scratching, hair-pulling, etc.)'  id='choice_23_223_25' tabindex='95'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_223_25' id='label_23_223_25'>Physical Aggression Towards Others (i.e.: hitting, kicking, biting, scratching, hair-pulling, etc.)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_223_26'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.26' type='checkbox'  value='Physical Aggression Towards Self (i.e.: hitting\/scratching self, biting self, head banging, other self-injurious behaviors, etc.)'  id='choice_23_223_26' tabindex='96'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_223_26' id='label_23_223_26'>Physical Aggression Towards Self (i.e.: hitting\/scratching self, biting self, head banging, other self-injurious behaviors, etc.)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_223_27'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.27' type='checkbox'  value='Destruction of Toys\/Property (i.e.: throwing\/destroying objects when upset, etc.)'  id='choice_23_223_27' tabindex='97'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_223_27' id='label_23_223_27'>Destruction of Toys\/Property (i.e.: throwing\/destroying objects when upset, etc.)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_223_28'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.28' type='checkbox'  value='Oppositional\/Defiant Towards Authority Figures'  id='choice_23_223_28' tabindex='98'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_223_28' id='label_23_223_28'>Oppositional\/Defiant Towards Authority Figures<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_223_29'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.29' type='checkbox'  value='Defiance\/Non-Compliance'  id='choice_23_223_29' tabindex='99'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_223_29' id='label_23_223_29'>Defiance\/Non-Compliance<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_223_31'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.31' type='checkbox'  value='Peers Appear Scared (or Stays Away) from Your Child'  id='choice_23_223_31' tabindex='100'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_223_31' id='label_23_223_31'>Peers Appear Scared (or Stays Away) from Your Child<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_223_32'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.32' type='checkbox'  value='Acts Immaturely (for their age)'  id='choice_23_223_32' tabindex='101'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_223_32' id='label_23_223_32'>Acts Immaturely (for their age)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_223_33'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.33' type='checkbox'  value='Acts Overly Mature (for their age)'  id='choice_23_223_33' tabindex='102'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_223_33' id='label_23_223_33'>Acts Overly Mature (for their age)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_223_34'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.34' type='checkbox'  value='Sensitive\/Moody\/Overly Emotional'  id='choice_23_223_34' tabindex='103'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_223_34' id='label_23_223_34'>Sensitive\/Moody\/Overly Emotional<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_223_35'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.35' type='checkbox'  value='Overly Rigid\/Inflexible'  id='choice_23_223_35' tabindex='104'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_223_35' id='label_23_223_35'>Overly Rigid\/Inflexible<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_223_36'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.36' type='checkbox'  value='Difficulty Tolerating Changes\/Transitions'  id='choice_23_223_36' tabindex='105'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_223_36' id='label_23_223_36'>Difficulty Tolerating Changes\/Transitions<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_223_37'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.37' type='checkbox'  value='Stealing'  id='choice_23_223_37' tabindex='106'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_223_37' id='label_23_223_37'>Stealing<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_223_38'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.38' type='checkbox'  value='Impulse Control Issues'  id='choice_23_223_38' tabindex='107'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_223_38' id='label_23_223_38'>Impulse Control Issues<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_223_39'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.39' type='checkbox'  value='Anger Issues'  id='choice_23_223_39' tabindex='108'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_223_39' id='label_23_223_39'>Anger Issues<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_223_41'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.41' type='checkbox'  value='Poor Eye Contact'  id='choice_23_223_41' tabindex='109'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_223_41' id='label_23_223_41'>Poor Eye Contact<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_223_42'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.42' type='checkbox'  value='Overly Perfectionistic'  id='choice_23_223_42' tabindex='110'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_223_42' id='label_23_223_42'>Overly Perfectionistic<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_223_43'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.43' type='checkbox'  value='Negative Attention-Seeking Behaviors'  id='choice_23_223_43' tabindex='111'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_223_43' id='label_23_223_43'>Negative Attention-Seeking Behaviors<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_223_44'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.44' type='checkbox'  value='Lacks Confidence'  id='choice_23_223_44' tabindex='112'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_223_44' id='label_23_223_44'>Lacks Confidence<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_223_45'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.45' type='checkbox'  value='Difficulty Initiating Interaction with Peers'  id='choice_23_223_45' tabindex='113'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_223_45' id='label_23_223_45'>Difficulty Initiating Interaction with Peers<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_223_46'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.46' type='checkbox'  value='Sensitive to Criticism'  id='choice_23_223_46' tabindex='114'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_223_46' id='label_23_223_46'>Sensitive to Criticism<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_223_47'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.47' type='checkbox'  value='Overly Harsh\/Critical of Self'  id='choice_23_223_47' tabindex='115'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_223_47' id='label_23_223_47'>Overly Harsh\/Critical of Self<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_223_48'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.48' type='checkbox'  value='Negative Self-Talk'  id='choice_23_223_48' tabindex='116'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_223_48' id='label_23_223_48'>Negative Self-Talk<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_223_49'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.49' type='checkbox'  value='Poor\/Low Self-Esteem'  id='choice_23_223_49' tabindex='117'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_223_49' id='label_23_223_49'>Poor\/Low Self-Esteem<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_223_51'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.51' type='checkbox'  value='Difficulty Sitting\/Staying Still'  id='choice_23_223_51' tabindex='118'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_223_51' id='label_23_223_51'>Difficulty Sitting\/Staying Still<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_223_52'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.52' type='checkbox'  value='Prefers Playing Alone\/Solidary Activities'  id='choice_23_223_52' tabindex='119'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_223_52' id='label_23_223_52'>Prefers Playing Alone\/Solidary Activities<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_223_53'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.53' type='checkbox'  value='Argumentative'  id='choice_23_223_53' tabindex='120'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_223_53' id='label_23_223_53'>Argumentative<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_223_54'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.54' type='checkbox'  value='Grouchy\/Irritable'  id='choice_23_223_54' tabindex='121'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_223_54' id='label_23_223_54'>Grouchy\/Irritable<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_223_55'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.55' type='checkbox'  value='Tends to Blame Others'  id='choice_23_223_55' tabindex='122'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_223_55' id='label_23_223_55'>Tends to Blame Others<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_223_56'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.56' type='checkbox'  value='Poor Judgement\/Insight (for their age)'  id='choice_23_223_56' tabindex='123'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_223_56' id='label_23_223_56'>Poor Judgement\/Insight (for their age)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_223_57'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.57' type='checkbox'  value='Deliberately Bothers\/Annoys Others'  id='choice_23_223_57' tabindex='124'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_223_57' id='label_23_223_57'>Deliberately Bothers\/Annoys Others<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_223_58'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.58' type='checkbox'  value='Weird\/Bizarre Behavior (please specify below)'  id='choice_23_223_58' tabindex='125'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_223_58' id='label_23_223_58'>Weird\/Bizarre Behavior (please specify below)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_223_59'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.59' type='checkbox'  value='Inappropriate Behavior (please specify below)'  id='choice_23_223_59' tabindex='126'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_223_59' id='label_23_223_59'>Inappropriate Behavior (please specify below)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_23_223_61'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.61' type='checkbox'  value='Other Behaviors of Concern (please specify below)'  id='choice_23_223_61' tabindex='127'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_223_61' id='label_23_223_61'>Other Behaviors of Concern (please specify below)<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_23_36\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_23_36' >In your own words, please provide a brief explanation of the areas that you feel your child struggles with\/have difficulty in and\/or discuss the reasons why you feel like your Child would benefit from participating in Social Skills Group:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_36' id='input_23_36' class='textarea medium' tabindex='128'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_23_41\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_23_41' >Please discuss your child&#039;s behavior\/performance in School and indicate how is your Child often described\/perceived as by his TEACHER (and\/or other adults that your child typically interacts with in the school setting)?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_41' id='input_23_41' class='textarea medium' tabindex='129'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_23_42\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_23_42' >Please indicate how your Child behaves in OTHER social settings (i.e.: out in the community, sports, extracurricular activities, with siblings\/cousins, other kids in the neighborhood, etc.):<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_42' id='input_23_42' class='textarea medium' tabindex='130'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_23_43\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_23_43' >Please indicate your Child&#039;s STRENGTHS and\/or any areas that your feel like your Child already does well:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_43' id='input_23_43' class='textarea medium' tabindex='131'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_23_189\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_23_189' >Please indicate some goals, areas, and\/or skills that you would like to see your Child IMPROVE in:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_189' id='input_23_189' class='textarea medium' tabindex='132'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_23_44\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_23_44' >Please provide any additional information that you feel like I need to know about your child in the space provided below (additional concerns or behavior, family\/living situation, background history, etc.):<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_44' id='input_23_44' class='textarea medium' tabindex='133'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_23_109\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h2 class=\"gsection_title\">General Healtlh<\/h2><\/li><li id=\"field_23_195\" class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" ><\/br>LMFT #108189<\/br>\nariel@thechildandfamilyconnection.com<\/br>\n949.221.4315<\/br>\n<\/br>\n151 Kalmus Drive, Building B, Suite 150<\/br>\nCosta Mesa, CA 92626<\/br>                                                     www.thechildandfamilyconnection.com<\/br><\/li><li id=\"field_23_224\" class=\"gfield gform_validation_container field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_23_224' >Email<\/label><div class='ginput_container'><input name='input_224' id='input_23_224' type='text' value='' \/><\/div><div class='gfield_description' id='gfield_description_23_224'>This field is for validation purposes and should be left unchanged.<\/div><\/li><\/ul><\/div>\n        <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_23' class='gform_button button' value='Submit' tabindex='134' onclick='if(window[\"gf_submitting_23\"]){return false;}  window[\"gf_submitting_23\"]=true;  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_23\"]){return false;} window[\"gf_submitting_23\"]=true;  jQuery(\"#gform_23\").trigger(\"submit\",[true]); }' \/> <input type='hidden' name='gform_ajax' value='form_id=23&amp;title=&amp;description=&amp;tabindex=1' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_23' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='23' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_23' value='WyJbXSIsIjc3YThjNzZiYjMzY2E3NDU5YjdhNTQ1ZmY4NDEzYTdmIl0=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_target_page_number_23' id='gform_target_page_number_23' value='0' \/>\n            <input type='hidden' class='gform_hidden' name='gform_source_page_number_23' id='gform_source_page_number_23' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <\/form>\n                        <\/div>\n                <iframe style='display:none;width:0px;height:0px;' src='about:blank' name='gform_ajax_frame_23' id='gform_ajax_frame_23' title='This iframe contains the logic required to handle Ajax powered Gravity Forms.'><\/iframe>\n                <script>\ngform.initializeOnLoaded( function() {gformInitSpinner( 23, 'https:\/\/thechildandfamilyconnection.com\/wp-content\/plugins\/gravityforms\/images\/spinner.svg' );jQuery('#gform_ajax_frame_23').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_23');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_23').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){jQuery('#gform_wrapper_23').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_23').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_23').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/ jQuery(document).scrollTop(jQuery('#gform_wrapper_23').offset().top - mt); }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_23').val();gformInitSpinner( 23, 'https:\/\/thechildandfamilyconnection.com\/wp-content\/plugins\/gravityforms\/images\/spinner.svg' );jQuery(document).trigger('gform_page_loaded', [23, current_page]);window['gf_submitting_23'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}setTimeout(function(){jQuery('#gform_wrapper_23').replaceWith(confirmation_content);jQuery(document).scrollTop(jQuery('#gf_23').offset().top - mt);jQuery(document).trigger('gform_confirmation_loaded', [23]);window['gf_submitting_23'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_23').text());}, 50);}else{jQuery('#gform_23').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger('gform_post_render', [23, current_page]);} );} );\n<\/script>\n\n\t\t\t\t\t\t<h5 tabindex=\"0\">Informed Consent to Treatment (Group Therapy)<\/h5>\n\t\t\t\n                <div class='gf_browser_unknown gform_wrapper gravity-theme' id='gform_wrapper_25' ><div id='gf_25' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_25' id='gform_25'  action='\/wp-json\/wp\/v2\/pages\/1078#gf_25' > \r\n <input type='hidden' class='gforms-pum' value='{\"closepopup\":false,\"closedelay\":0,\"openpopup\":false,\"openpopup_id\":0}' \/>\n                        <div class='gform_body gform-body'><div id='gform_fields_25' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_25_7\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h3 class=\"gsection_title\">Informed Consent for Psychoeducational Group<\/h3><div class='gsection_description' id='gfield_description_25_7'>Social Skills Group<\/div><\/div><div id=\"field_25_1\" class=\"gfield gfield_html gfield_html_formatted field_sublabel_below field_description_below gfield_visibility_visible\" ><p><strong>Welcome!<\/strong><\/p>\n<p>We are pleased to offer a Social Skills Group, which is designed to provide opportunities for children to learn and practice social skills in a safe and supportive environment. This program is led by trained professionals who have experience working with children in this area.<\/p>\n<p>The state expects that you will be informed of all possible contingencies that might arise in the course of any interaction with a Licensed Marriage &amp; Family Therapist, including the psychoeducational groups indicated above. It is important to be clear about the nature of a psychoeducational group experience. Please read the information below and raise any questions that you may have so that we can discuss them.<\/p>\n<p><strong>Service Provider:<\/strong> Bee-Yu (Ariel) Yung, The Child and Family Connection<\/p>\n<p><strong>Registration:<\/strong> Licensed Marriage and Family Therapist, California Board of Behavioral Sciences #LMFT 108189<\/p>\n<p><strong>Credentials:<\/strong> I am a Licensed Therapist in the state of California. Areas of specialization include early childhood development, poor coping\/emotional regulation issues, depression, anxiety, trauma\/PTSD, ADHD, disruptive behavior, parenting skills, and relationship issues.<\/p>\n<p><strong>Description of the Program:<\/strong><\/p>\n<p>The Social Skills Group is a program that provides a fun and interactive way for children to learn and practice social skills. This social skills group course is designed to teach your child important and essential pro-social skills in a fun and engaging manner. Each week, we will be focusing on a different topic area including Getting to know one another, Friendship\/making &amp; keeping friends, Sharing\/taking turns, Listening\/following directions, Managing emotions\/healthy coping skills, Manners, Kindness\/empathy, and Teamwork\/cooperation. Each week&rsquo;s lesson is specifically crafted to be for your child&rsquo;s developmental level, accompanied by related age-appropriate activities which allows your child to practice the skills taught in a safe, non-judgmental, and nurturing environment. As the Facilitator, I will be using prompting, coaching, redirection, feedback, and positive reinforcement to guide\/assist your child in navigating through various social scenarios\/situations with his\/her peers.<\/p>\n\n<p>Within this social skills group course, not only will your child have the opportunity to meet and connect with other kids his\/her age, your child will also learn how to interact with his\/her peers in a more positive and socially appropriate manner, which will in turn allow your child to have deeper, more meaningful relationships with others later on in life.<\/p>\n<p><strong>Psychoeducation vs. Psychotherapy:<\/strong><\/p>\n<p>You understand that this psychoeducational group experience is purely &ldquo;educational&rdquo; in design and purpose, and is not &ldquo;therapeutic&quot; (i.e., it is NOT a replacement for individual therapy or for group therapy). In these psychoeducational group sessions, I will serve as the facilitator and present to attendees scientific and theoretical material that is applicable to various life circumstances and problems, and there will be ample time for discussion. If issues arise that are not suitable for this educational experience, you may benefit from formal psychotherapy and you agree to consult with me and\/or another mental health professionals to obtain referral information. You realize that you may obtain formal psychotherapy services from Bee-Yu (Ariel) Yung, LMFT upon arrangement, but you realize that these psychotherapy services are entirely distinct and separate from the psychoeducational group experience.<\/p>\n<p><strong>Goals of the Program:<\/strong><\/p>\n<p>The primary goals of the Social Skills Group are:<\/p>\n<ul>\n    <li>To help children learn and practice social skills in a supportive and engaging environment.<\/li>\n    <li>To provide opportunities for children to interact with peers and develop positive relationships.<\/li>\n    <li>To improve children&apos;s self-esteem and confidence in social situations.<\/li>\n    <li>To promote emotional regulation and coping skills.<\/li>\n<\/ul>\n<p><strong>Risks and Benefits:<\/strong><\/p>\n<p>Participating in a psychoeducational group experience can have benefits and risks. Psychoeducation has been shown to have many benefits, including the experience of insight, increased understanding, and positive feelings. However, since psychoeducation may involve discussing many parts of your life, including, at times, the unpleasant aspects, you may also experience uncomfortable feelings. You should be aware that psychoeducation may or may not lead to direct improvements in your life. You should also be aware that if psychoeducation induces change in your life, these changes may disrupt your accustomed manner of living and your relationships with others.<\/p>\n<p>The benefits may include:<\/p>\n<ul>\n    <li>Improved social skills, including communication, cooperation, problem-solving, and empathy.<\/li>\n    <li>Increased self-esteem and confidence in social situations.<\/li>\n<\/ul>\n\n<ul>\n    <li>Opportunities for positive social interactions and relationship-building with peers.<\/li>\n    <li>Improved emotional regulation and coping skills.<\/li>\n<\/ul>\n<p><strong>Your Rights:<\/strong><\/p>\n<p>In a private practice such as this, psychoeducation is entirely voluntary and you have the right to terminate your experience at any time. In all cases, psychoeducation never includes sexual contact with the facilitator. Please be advised that I also reserve the right to terminate your involvement in psychoeducation if recommended consultations are not obtained, or if some problem emerges that is not within the scope of my competence.<\/p>\n<p><strong>Protecting the Confidentiality of Other Attendees:<\/strong><\/p>\n<p>With full understanding of the need for confidentiality (that is, privacy) for all attendees, you accept these following rules:<\/p>\n<ol>\n    <li>You will not disclose personal information about other attendees to anyone;<\/li>\n    <li>other information (such as phone numbers) can be exchanged between attendees only on a person-to-person basis;<\/li>\n    <li>any activity between attendees outside of the psychoeducational group experience is solely based on the choice of these attendees and is not the responsibility of the facilitator. You understand that you cannot be absolutely certain that other attendees will always keep what you say in the sessions confidential even though every attendee has agreed to secrecy. The other attendees do not serve in the role of facilitator\/LMFT and are therefore not obligated to maintain the same ethics and laws that the facilitator must work under.<\/li>\n<\/ol>\n<p><strong>About the Relationship with the Facilitator:<\/strong><\/p>\n<p>Because of the nature of the psychoeducational group experience, the relationship between the facilitator (Bee-Yu Yung, LMFT) and the attendees has to be different from most relationships. It must be limited to the relationship of facilitator and attendee only. If we were to interact in any other ways (including socially, business, legal, medical, financial, sexual or romantic) we would then have a &ldquo;dual\/multiple relationship&rdquo; and violate important ethical principles for Licensed Marriage &amp; Family Therapists (LMFTs). LMFTs are obligated by legal and ethical mandates to avoid dual relationships situations so as to protect the public. You should also know that LMFTs are required to keep the identity of their clients (and psychoeducational group attendees) private and confidential. Lastly, when our work together in this psychoeducational group experience is completed, I will not be able to be a friend to you like your other friends or engage with you in any way socially or romantically. In sum, my duty as facilitator\/LMFT is to care for you and my other clients, but only in my professional role.<\/p>\n\n<p><strong>Limits of Confidentiality:<\/strong><\/p>\n<p>The law protects the privacy of all communications between client and a LMFT. In most situations, the LMFT can only release information about his\/her work with you to others if you sign a written authorization form that meets certain legal requirements imposed by HIPAA. However, there are some exceptions in which a LMFT may be permitted or is required to disclose confidential client information without either the client&rsquo;s consent or authorization. These situations including the following:<\/p>\n<ol>\n    <li>If I have reasonable cause to believe (i.e., reasonable suspicion or evidence) based on a client&rsquo;s communication that a child under age 18 is suffering physical or emotional injury resulting from abuse inflicted upon him or her which causes harm or substantial risk of harm to the child&apos;s health or welfare (including sexual abuse), or from neglect (including malnutrition), the law requires that I file a report with the appropriate social service (Child Protective Services) and legal authorities. In addition, if a client reports that he\/she was physically or sexually abused as a child, or engaged in sexual acts with an adult while a child, and the reported perpetrator currently has access to children, the law requires that I file a report with the appropriate social service (Child Protective Services) and legal authorities.<\/li>\n    <li>If I have reason to believe an elderly or handicapped individual is suffering from abuse or maltreatment, the law requires that I file a report with a law agency and\/or the State Department of Social Services.<\/li>\n    <li>If a client communicates an immediate threat (i.e., with clear intentionality of harm or a plan to harm) of serious physical harm to an identifiable victim, I may be required to take protective actions. These actions may include notifying the potential victim, contacting the police, and\/or seeking hospitalization for the patient.<\/li>\n    <li>If a client threatens to harm himself\/herself (i.e., communicates intent and\/or a plan for suicide), I am required to notify legal authorities and make reasonable attempts to notify the client&rsquo;s family members or others who can help provide protection.<\/li>\n    <li>If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself.<\/li>\n<\/ol>\n<p><strong>Professional Records:<\/strong><\/p>\n<p>You have specific rights with regard to your clinical record. Your file will remain active while you are participating in treatment. When our work concludes, or it has been at least 30 days since our last contact, your file will be closed. You may request amendments to your record, request to restrict the information disclosed to others, request an accounting of disclosures, and determine the location to which protected health information is sent (please see my Notice of Privacy Practices for more information). The laws and standards of my profession require that I keep treatment records. Except in specific circumstances, you are entitled to examine your child&rsquo;s clinical record and\/or receive a copy at a rate of &cent;25 per page. If you wish to see you or<\/p>\n\n<p>your child&rsquo;s records, you must request to do so in writing. Because these are professional records, they can be misinterpreted and\/or upsetting to untrained readers. In the event that you do review the full records I recommend that they are reviewed in my presence so that we can discuss the contents. Clients will be charged an appropriate fee for any professional time spent in responding to information requests. You may request that any complaints you have about my privacy policies and procedures be<\/p>\n<p><strong>Fee for Service &amp; Insurance:<\/strong><\/p>\n<p>My fee is $150.00 per 120-minute psychoeducational group session (or a total of $600.00 for all 4 group sessions. Payment is due at the beginning of each group session. Credit card information will be collected prior to the start of the group and $150.00 will be charged for each session.<\/p>\n<p><strong>Unpaid Balances:<\/strong><\/p>\n<p>There will be a returned check fee of $25.00 should there be any problems clearing your check. If for any reason you do not pay your bill at the time of service, a $50.00 late fee will be assessed for each 30-days that you do not pay. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through a small claims court. If such legal action is necessary, its costs will be included in the claim. In most collection situations, the only information I release regarding a client&rsquo;s treatment is their name, the nature of services provided, and the amount due.<\/p>\n<p><strong>Other Requests (Forensic Activity, Letter-Writing, and Release of the Medical Record)<\/strong><\/p>\n<p>The professional services provided to you in my practice are limited to those that are clinical and psychoeducational in nature. This is to ensure that I maintain a singular role with you, a role that represents my expertise. Given this, please be aware of the following potential requests that would directly or indirectly place me outside of my role:<\/p>\n<ol>\n    <li><strong><em>I<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>do<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>not<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>have<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>an<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>expertise<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>in<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>forensic<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>matters.<\/em><\/strong> Consequently, if you currently have, or plan to address, a legal situation in which you seek my involvement as your psychologist, I am not the best choice. Functions such as conducting court-related evaluations, providing letters to attorneys and\/or judges, testifying in court, serving as your court-mandated treatment provider, etc. require highly specialized training, are outside of the scope of my professional competence, and are better suited for forensic practitioners. My potential participation in these activities merges therapeutic and forensic roles and, in most circumstances, is unethical.<\/li>\n    <li><strong>R<em>equests<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>for<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>additional<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>administrative<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>services<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>(such<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>as,<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>but<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>not limited<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>to,<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>assessment<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>of<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>disability<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>certification<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>or<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>advocating<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>for special<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>accommodations<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>related<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>to<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>a<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>psychological<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>condition)<\/em><\/strong> will<\/li>\n<\/ol>\n\n<p>have to be provided by another psychologist in accordance with the rationale indicated above, i.e., these types of professional activities are forensic in nature and should not be conducted by a psychologist acting within a clinical or psychoeducational role.<\/p>\n<ol>\n    <li><strong><em>As alluded to in point (a) above, letters are occasionally requested of<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>their<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>therapist by clients.<\/em><\/strong> Generally, the Board of Psychology in California and\/or the Board of Behavioral Sciences and legal\/ethical experts encourage clinicians to refrain from letter-writing as most letter requests are related to legal matters. Consequently, if a clincian agrees to write such a letter, he or she risks exposure to a legal action and, also, the letter itself may be construed as a professional action that is outside of the clinical or psychoeducational role. In most situations I will opt out of writing letters and will refer the client to an appropriate professional who can address the need at hand.<\/li>\n    <li><strong>T<em>echnically,<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>the<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>medical<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>(treatment)<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>record<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>is<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>the<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>possession<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>of the<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>client.<\/em><\/strong> Because you are engaging in psychoeducation and not formal treatment, you technically will not have a treatment record. What will be recorded is any communication you have with me, the dates of your attendance in psychoeducational sessions as well as a summary of topics discussed, and fees paid. When a client provides authorization for the release of the record to a third party, it is incumbent upon the clinician to discuss with the client the circumstances regarding the release of the record and the potential risks involved. In many situations, it is often legally and clinically prudent for a summary of the record to be released (rather than the entire record).<strong><em> <\/em><\/strong><strong><em>In addition,<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>when<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>treatment<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>(or<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>any<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>specific<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>session<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>within<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>a<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>course of treatment)<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>consists<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>of<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>more<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>than<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>one<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>party<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>involved<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>in<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>a<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>session,<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>in most<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>situations<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>the<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>record<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>or<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>any<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>portion<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>of<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>the<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>record<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>can<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>be released<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>only<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>if<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>the<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>expressed<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>written<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>consent\/authorization<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>of<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>all parties<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>involved<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>has<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>been<\/em><\/strong><strong><em> <\/em><\/strong><strong><em>obtained.<\/em><\/strong> Finally, as indicated above, an administrative fee rate is applied to the time it takes for the preparation of materials associated with the release of a medical record.<\/li>\n<\/ol>\n<p><strong>Arrival at The Child and Family Connection:<\/strong><\/p>\n<p>When you arrive at our office, please follow the signs for the Social Skills Group. Parents are expected to bring their child to group sessions personally (unless arranged in advance with The Child and Family Connection) and must stay in the waiting room or immediate area during the session, as parents need to be able to be reached in case of any emergencies. Additionally, parents are also expected to be on hand to take a child to the restroom during group sessions, as needed.<\/p>\n<p>Please be aware that I will be unavailable to take your call during social skills group time, as I am busy running\/facilitating group at that time. However, in the event that you need to contact me, please call or text to my confidential voice mailbox<strong> <\/strong><strong>(949)<\/strong><\/p>\n\n<p><strong>221-4315<\/strong>. I check my messages a few times a day Monday through Saturday, unless I am away from the office. If an urgent situation arises, please indicate it clearly in your message and I will get back to you as soon as possible. However, in the event of a real emergency and you need to talk to someone right away, please dial 911 or go to your nearest hospital emergency room.<\/p><\/div><div id=\"field_25_8\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h3 class=\"gsection_title\">Agreement for Psychoeducational Group<\/h3><div class='gsection_description' id='gfield_description_25_8'>By signing below, you show that you have read and understood the policies described above and agree to abide by this \u201cInformed Consent for Psychoeducational Group\u201d. If you have any questions as we progress with therapy, you can ask me at any time.<\/div><\/div><div id=\"field_25_2\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_25_2' >Name of Group Participant:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_2' id='input_25_2' type='text' value='' class='large'   tabindex='5'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_25_3\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_25_3' >Parent\/Guardian Signature<\/label><div ><div id='input_25_3_Container' class='gfield_signature_container ginput_container' style='height:180px; width:400px; ' ><input type='hidden' class='gform_hidden' name='input_25_3_valid' id='input_25_3_valid' \/><canvas id='input_25_3' width='400' height='180'><\/canvas><\/div><\/div><\/div><div id=\"field_25_5\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_25_5' >Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_5' id='input_25_5' type='text' value='04\/30\/2024' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon' tabindex='6'  placeholder='mm\/dd\/yyyy' aria-describedby=\"input_25_5_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_25_5_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_25_5' class='gform_hidden' value='https:\/\/thechildandfamilyconnection.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_25_4\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_25_4' >Parent\/Guardian Signature<\/label><div ><div id='input_25_4_Container' class='gfield_signature_container ginput_container' style='height:180px; width:400px; ' ><input type='hidden' class='gform_hidden' name='input_25_4_valid' id='input_25_4_valid' \/><canvas id='input_25_4' width='400' height='180'><\/canvas><\/div><\/div><\/div><div id=\"field_25_6\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_25_6' >Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_6' id='input_25_6' type='text' value='04\/30\/2024' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon' tabindex='7'  placeholder='mm\/dd\/yyyy' aria-describedby=\"input_25_6_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_25_6_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_25_6' class='gform_hidden' value='https:\/\/thechildandfamilyconnection.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><\/div><\/div>\n        <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_25' class='gform_button button' value='Submit' tabindex='8' onclick='if(window[\"gf_submitting_25\"]){return false;}  window[\"gf_submitting_25\"]=true;  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_25\"]){return false;} window[\"gf_submitting_25\"]=true;  jQuery(\"#gform_25\").trigger(\"submit\",[true]); }' \/> <input type='hidden' name='gform_ajax' value='form_id=25&amp;title=&amp;description=&amp;tabindex=5' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_25' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='25' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_25' value='WyJbXSIsIjc3YThjNzZiYjMzY2E3NDU5YjdhNTQ1ZmY4NDEzYTdmIl0=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_target_page_number_25' id='gform_target_page_number_25' value='0' \/>\n            <input type='hidden' class='gform_hidden' name='gform_source_page_number_25' id='gform_source_page_number_25' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <\/form>\n                        <\/div>\n                <iframe style='display:none;width:0px;height:0px;' src='about:blank' name='gform_ajax_frame_25' id='gform_ajax_frame_25' title='This iframe contains the logic required to handle Ajax powered Gravity Forms.'><\/iframe>\n                <script>\ngform.initializeOnLoaded( function() {gformInitSpinner( 25, 'https:\/\/thechildandfamilyconnection.com\/wp-content\/plugins\/gravityforms\/images\/spinner.svg' );jQuery('#gform_ajax_frame_25').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_25');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_25').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 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contents;}setTimeout(function(){jQuery('#gform_wrapper_25').replaceWith(confirmation_content);jQuery(document).scrollTop(jQuery('#gf_25').offset().top - mt);jQuery(document).trigger('gform_confirmation_loaded', [25]);window['gf_submitting_25'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_25').text());}, 50);}else{jQuery('#gform_25').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger('gform_post_render', [25, current_page]);} );} );\n<\/script>\n\n\t\t\t\t\t\t<h5 tabindex=\"0\">Financial Responsibility<\/h5>\n\t\t\t\n                <div class='gf_browser_unknown gform_wrapper gravity-theme' id='gform_wrapper_24' ><div id='gf_24' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_24' id='gform_24'  action='\/wp-json\/wp\/v2\/pages\/1078#gf_24' > \r\n <input type='hidden' class='gforms-pum' value='{\"closepopup\":false,\"closedelay\":0,\"openpopup\":false,\"openpopup_id\":0}' \/>\n                        <div class='gform_body gform-body'><div id='gform_fields_24' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_24_1\" class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_24_1' >Patient Name:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_24_1' type='text' value='' class='large'   tabindex='5'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_24_2\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_24_2' >Parent\/Guardian\/Spouse (if applicable):<\/label><div class='ginput_container ginput_container_text'><input name='input_2' id='input_24_2' type='text' value='' class='large'   tabindex='6'   aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_24_3\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Address:<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address' id='input_24_3' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1' id='input_24_3_1_container' >\n                                        <input type='text' name='input_3.1' id='input_24_3_1' value='' tabindex='7'   aria-required='false'    \/>\n                                        <label for='input_24_3_1' id='input_24_3_1_label' >Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2' id='input_24_3_2_container' >\n                                        <input type='text' name='input_3.2' id='input_24_3_2' value='' tabindex='8'    aria-required='false'   \/>\n                                        <label for='input_24_3_2' id='input_24_3_2_label' >Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city' id='input_24_3_3_container' >\n                                    <input type='text' name='input_3.3' id='input_24_3_3' value='' tabindex='9'   aria-required='false'    \/>\n                                    <label for='input_24_3_3' id='input_24_3_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state' id='input_24_3_4_container' >\n                                        <input type='text' name='input_3.4' id='input_24_3_4' value='' tabindex='11'     aria-required='false'    \/>\n                                        <label for='input_24_3_4' id='input_24_3_4_label' >State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip' id='input_24_3_5_container' >\n                                    <input type='text' name='input_3.5' id='input_24_3_5' value='' tabindex='12'   aria-required='false'    \/>\n                                    <label for='input_24_3_5' id='input_24_3_5_label' >ZIP \/ Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_3.6' id='input_24_3_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_24_4\" class=\"gfield gfield--width-half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_24_4' >Phone:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_4' id='input_24_4' type='text' value='' class='large' tabindex='13'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_24_5\" class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_24_5' >Email:<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_5' id='input_24_5' type='text' value='' class='large' tabindex='14'    aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_24_6\" class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" ><h4><b><i>The patient and\/or guardian are ultimately responsible for payment of all services. As a result, it is our policy to have a credit\/debit card on file for each patient. Check or cash is otherwise accepted at time of visit.<\/i><\/b><\/h4><\/div><div id=\"field_24_7\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_24_7' >CARDHOLDER NAME:<\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_24_7' type='text' value='' class='large'   tabindex='15'   aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_24_8\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><legend class='gfield_label gfield_label_before_complex'  >Billing Address:<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address' id='input_24_8' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1' id='input_24_8_1_container' >\n                                        <input type='text' name='input_8.1' id='input_24_8_1' value='' tabindex='16'   aria-required='false'    \/>\n                                        <label for='input_24_8_1' id='input_24_8_1_label' >Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2' id='input_24_8_2_container' >\n                                        <input type='text' name='input_8.2' id='input_24_8_2' value='' tabindex='17'    aria-required='false'   \/>\n                                        <label for='input_24_8_2' id='input_24_8_2_label' >Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city' id='input_24_8_3_container' >\n                                    <input type='text' name='input_8.3' id='input_24_8_3' value='' tabindex='18'   aria-required='false'    \/>\n                                    <label for='input_24_8_3' id='input_24_8_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state' id='input_24_8_4_container' >\n                                        <input type='text' name='input_8.4' id='input_24_8_4' value='' tabindex='20'     aria-required='false'    \/>\n                                        <label for='input_24_8_4' id='input_24_8_4_label' >State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip' id='input_24_8_5_container' >\n                                    <input type='text' name='input_8.5' id='input_24_8_5' value='' tabindex='21'   aria-required='false'    \/>\n                                    <label for='input_24_8_5' id='input_24_8_5_label' >ZIP \/ Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_8.6' id='input_24_8_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_24_11\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_24_11' >Card Number:<\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_24_11' type='text' value='' class='large'   tabindex='22'   aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_24_10\" class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_24_10' >Expiration Date:<\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_24_10' type='text' value='' class='large'   tabindex='23'   aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_24_12\" class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_24_12' >CVV Code:<\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_24_12' type='text' value='' class='large'   tabindex='24'   aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_24_13\" class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\" ><h3>PAYMENT POLICY<\/h3>\n<h5>\nI agree to be responsible for the per social skills group fee of $150.00 and authorize The Child and Family Connection to charge my credit card for the amounts due. I certify that I am the authorized user of this credit card and that my signature below indicates that I have read this Agreement and agree to its terms and conditions.<\/h5><\/div><div id=\"field_24_14\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_24_14' >Client Signature<\/label><div ><div id='input_24_14_Container' class='gfield_signature_container ginput_container' style='height:180px; width:400px; ' ><input type='hidden' class='gform_hidden' name='input_24_14_valid' id='input_24_14_valid' \/><canvas id='input_24_14' width='400' height='180'><\/canvas><\/div><\/div><\/div><div id=\"field_24_15\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_24_15' >Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_15' id='input_24_15' type='text' value='04\/30\/2024' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon' tabindex='25'  placeholder='mm\/dd\/yyyy' aria-describedby=\"input_24_15_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_24_15_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_24_15' class='gform_hidden' value='https:\/\/thechildandfamilyconnection.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_24_16\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_24_16' >Authorized Signature for Client<\/label><div ><div id='input_24_16_Container' class='gfield_signature_container ginput_container' style='height:180px; width:400px; ' ><input type='hidden' class='gform_hidden' name='input_24_16_valid' id='input_24_16_valid' \/><canvas id='input_24_16' width='400' height='180'><\/canvas><\/div><\/div><\/div><div id=\"field_24_17\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_24_17' >Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_17' id='input_24_17' type='text' value='04\/30\/2024' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon' tabindex='26'  placeholder='mm\/dd\/yyyy' aria-describedby=\"input_24_17_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_24_17_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_24_17' class='gform_hidden' value='https:\/\/thechildandfamilyconnection.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><\/div><\/div>\n        <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_24' class='gform_button button' value='Submit' tabindex='27' onclick='if(window[\"gf_submitting_24\"]){return false;}  window[\"gf_submitting_24\"]=true;  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_24\"]){return false;} window[\"gf_submitting_24\"]=true;  jQuery(\"#gform_24\").trigger(\"submit\",[true]); }' \/> <input type='hidden' name='gform_ajax' value='form_id=24&amp;title=&amp;description=&amp;tabindex=5' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_24' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='24' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_24' value='WyJbXSIsIjc3YThjNzZiYjMzY2E3NDU5YjdhNTQ1ZmY4NDEzYTdmIl0=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_target_page_number_24' id='gform_target_page_number_24' value='0' \/>\n            <input type='hidden' class='gform_hidden' name='gform_source_page_number_24' id='gform_source_page_number_24' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <\/form>\n                        <\/div>\n                <iframe style='display:none;width:0px;height:0px;' src='about:blank' name='gform_ajax_frame_24' id='gform_ajax_frame_24' title='This iframe contains the logic required to handle Ajax powered Gravity Forms.'><\/iframe>\n                <script>\ngform.initializeOnLoaded( function() {gformInitSpinner( 24, 'https:\/\/thechildandfamilyconnection.com\/wp-content\/plugins\/gravityforms\/images\/spinner.svg' );jQuery('#gform_ajax_frame_24').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_24');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_24').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){jQuery('#gform_wrapper_24').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_24').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_24').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/ jQuery(document).scrollTop(jQuery('#gform_wrapper_24').offset().top - mt); }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_24').val();gformInitSpinner( 24, 'https:\/\/thechildandfamilyconnection.com\/wp-content\/plugins\/gravityforms\/images\/spinner.svg' );jQuery(document).trigger('gform_page_loaded', [24, current_page]);window['gf_submitting_24'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}setTimeout(function(){jQuery('#gform_wrapper_24').replaceWith(confirmation_content);jQuery(document).scrollTop(jQuery('#gf_24').offset().top - mt);jQuery(document).trigger('gform_confirmation_loaded', [24]);window['gf_submitting_24'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_24').text());}, 50);}else{jQuery('#gform_24').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger('gform_post_render', [24, current_page]);} );} );\n<\/script>\n\n\t\t\t\t\t\t<h5 tabindex=\"0\">HIPAA<\/h5>\n\t\t\t\n                <div class='gf_browser_unknown gform_wrapper gravity-theme' id='gform_wrapper_26' ><div id='gf_26' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_26' id='gform_26'  action='\/wp-json\/wp\/v2\/pages\/1078#gf_26' > \r\n <input type='hidden' class='gforms-pum' value='{\"closepopup\":false,\"closedelay\":0,\"openpopup\":false,\"openpopup_id\":0}' \/>\n                        <div class='gform_body gform-body'><div id='gform_fields_26' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_26_7\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h3 class=\"gsection_title\">HIPAA for Psychoeducational Group<\/h3><div class='gsection_description' id='gfield_description_26_7'>Social Skills Group<\/div><\/div><div id=\"field_26_1\" class=\"gfield gfield_html gfield_html_formatted field_sublabel_below field_description_below gfield_visibility_visible\" ><p>Required HIPAA Notice of Privacy Practices<\/p>\n\n<p>I. THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. IT WILL GENERALLY PROTECT YOUR PRIVACY TO A MUCH GREATER DEGREE THAN REQUIRED BY THE LANGUAGE OF THE DOCUMENT.<\/p>\n\n<p>II. I HAVE A LEGAL DUTY TO SAFEGUARD YOUR PROTECTED HEALTH INFORMATION (PHI)<\/p>\n\n<p>I am legally required to protect the privacy of your PHI, which includes information that can be used to identify you which I have created or received about your past, present, or future health or condition, the provision of health care to you, or the payment of the health care. I must provide you with this Notice about my privacy practices and such Notice must explain how, when, and why I will &ldquo;use&rdquo; and &ldquo;disclose&rdquo; your PHI. A &ldquo;use&rdquo; of PHI occurs when I share, examine, give, or otherwise disclose to a third party outside of my practice. With some exceptions, I may not use or disclose any more of your PHI than is necessary to accomplish the purpose for which the use or disclosure is made. I am legally required to follow the privacy practices described in this Notice; however, I reserve the right to change the terms of the Notice and my privacy policies at any time. Any changes will apply to PHI on file with me already. Before I make any important changes to my policies, I will promptly change this Notice and post a new copy of it in my office.<\/p>\n\n<p>III. HOW I MAY USE AND DISCLOSE YOUR PHI<\/p>\n\n<p>I will use and disclose your PHI for many different reasons. I will need your prior written authorization for some of these uses or disclosures; for others, however, I do not. Listed below are the different categories of my uses and disclosures along with some examples of each category.<\/p>\n\n<p>A. Uses and Disclosures. Relating to Treatment, Payment, or Health Care Operations Do Not Require Your Prior Written Consent. I can use and disclose your PHI without your consent for the following reasons:<\/p>\n\n<p>For Treatment. I can use your PHI within my practice to provide you with mental health treatment. I can disclose your PHI to physicians, psychiatrists, psychologists, and other licensed health care providers who provide you with health care services or are involved in your case.<\/p>\n\n<p>To Obtain Payment for Treatment. I can use your PHI to bill and collect payment for the treatment and services provided by me to you. For example, I might send your PHI to your insurance company or health plan to get paid for the health care services provided to you. I may also provide your PHI to my business associates, such as billing companies, claims processing companies, and others that process health care claims.<\/p>\n\n<p>For Health Care Operations. I can use and disclose your PHI to operate my practice. For example, I might use your PHI to evaluate the quality of health care services that you received or to evaluate the performance of the health care professionals who have provided such services to you. I may also provide your PHI to my accountant, attorney, consultants, or others to further my health care operations.<\/p>\n\n<p>For Patient Incapacitation or Emergency. I may also disclose your PHI to others without your consent if you are incapacitated or if an emergency exists. For example, your consent is not required if you need emergency treatment as long as I try to get your consent after treatment is rendered; or, if I try to get your consent but you are unable to communicate with me (for example, if you are unconscious or in severe pain) and I think that you would consent to such treatment if you were able to do so.<\/p>\n\n<p>B. Certain Other Uses and Disclosures Also Do Not Require Your Consent or Authorization. I can use and disclose your PHI without your consent or authorization for the following reasons:<\/p>\n\n<p>1. When federal, state, or local laws require disclosure. For example, I may have to make a disclosure to applicable governmental officials when a law requires me to report information to governmental agencies and law enforcement personnel about victims of abuse or neglect.<\/p>\n\n<p>2. When judicial or administrative proceedings require disclosure. For example, I may have to use or disclose your PHI in response to a court or administrative order if you are involved in a lawsuit or claim for workers&rsquo; compensation benefits. I may also have to use or disclose your PHI in response to a subpoena.<\/p>\n\n<p>3. When law enforcement requires disclosure. For example, I may have to use or disclose your PHI in response to a search warrant.<\/p>\n\n<p>4. When public health activities require disclosure. For example, I may have to use or disclose your PHI to report to a governmental official an adverse reaction that you may have to a medication.<\/p>\n\n<p>5. When health oversight activities require disclosure. For example, I may have to provide information to assist the government in conducting an investigation or inspection of a health care provider or organization.<\/p>\n\n<p>6. To avert a serious threat to health or safety. For example, I may have to use or disclose your PHI to avert a serious threat to the health or safety of others. Any such disclosures will only be made to someone able to prevent the threatening harm from occurring.<\/p>\n\n<p>7. For specialized government functions. For example, I may have to use or disclose your PHI for national security purposes, including protecting the President of the United States or conducting intelligence operations, if you are in the military.<\/p>\n\n<p>8. To remind you about appointments and to inform you of health-related benefits or services. For example, I may have to use or disclose your PHI to remind you about your appointments or to give you information about treatment alternatives, other health care services, or other health care benefits that I offer that may be of interest to you.<\/p>\n\n<p>C. Certain Uses and Disclosures Require You to Have the Opportunity to Object.<\/p>\n\n<p>Disclosures to family, friends, or others: I may provide your PHI to a family member, friend, or other person that you indicate that is involved in your care or the payment for your health care unless you object in whole or in part. The opportunity to consent may be obtained retroactively in an emergency situation.<\/p>\n\n<p>D. Other Uses and Disclosures Require Your Prior Written Authorization. In any situation not described in sections III A, B, and C, above, I will need your written authorization before using or disclosing any of your PHI. If you choose to sign an authorization to disclose your PHI, you can later revoke such authorization in writing to stop any future uses and disclosures (to the extent that I have not taken any action in reliance on such authorization) of your PHI by me.<\/p>\n\n<p>IV. WHAT RIGHTS YOU HAVE REGARDING YOUR PHI<\/p>\n\n<p>You have the following rights with respect to your PHI:<\/p>\n\n<p>A. The Right to Request Restrictions on My Uses and Disclosures. You have the right to request restrictions or limitations on my uses or disclosures of your PHI to carry out my treatment, payment, or health care operations. You also have the right to request that I restrict or limit disclosures of your PHI to family members, friends, or others involved in your care or who are financially responsible for your care. Please submit such requests to me in writing. I will consider your requests but am not legally required to accept them. If I do accept your requests I will put them in writing and will abide by them except in emergency situations. Be advised that you may not limit the uses and disclosures that I am legally required to make.<\/p>\n\n<p>B. The Right to Choose How I Send PHI to You. You have the right to request that I send confidential information to you at an alternate address (for example, sending information to your work address rather than your home address) or by alternate means (for example, e-mail instead of regular mail). I must agree to your request so long as it is reasonable and you specify how or where you wish to be contacted, and when appropriate, provide me with information as to how payment for such alternate communications will be handled. I may not require an explanation from you as to the basis of your request as a condition of providing communications on a confidential basis.<\/p>\n\n<p>C. The Right to Inspect and Receive a Copy of Your PHI. In most cases, you have the right to inspect and receive a copy of the PHI that I have on you, but you must make the request to inspect and receive a copy of such information in writing. If I do not have your PHI but I know who does, I will tell you how to get it. I will respond to your request within 30 days of receiving your written request. In certain situations, I may deny your request. If I do, I will tell you, in writing, my reasons for the denial and explain your right to have my denial reviewed.<\/p>\n\n<p>D. The Right to Receive a List of the Disclosures I Have Made. You have the right to receive an Accounting of Disclosure listing the instances in which I have disclosed your PHI. The list will not include disclosures made for my treatment, payment, or health care operations; disclosures made to you; disclosures you authorized; disclosures incident to a use; disclosures permitted or required by the federal privacy rule; disclosures made for national security or intelligence; disclosures made to correctional institutions or law enforcement personnel; and, disclosures made before April 14, 2003. I will respond to your request for an Accounting of Disclosure within 60 days of receiving such request. The list I will give you will include disclosures made in the last six years unless you request a shorter time. The list will include the date the disclosure was made, to whom the PHI was disclosed (including their address, if known), a description of the information disclosed, and the reason for the disclosure. I will provide the list to you at no charge, but if you make more than one request in the same year I may charge you a reasonable, cost-based fee for each additional request.<\/p>\n\n<p>E. The Right to Amend Your PHI. If you believe that there is a mistake in your PHI or that a piece of important information is missing, you have the right to request that I correct the existing information or add the missing information. You must provide, in writing, the request and your reason for the request. I will respond within 60 days of receiving your request to correct or update your PHI. I may deny your request in writing if the PHI is (i) correct and complete, (ii) not created by me, (iii) not allowed to be disclosed, or (iv) not part of my records. My written denial will state the reasons for the denial and explain your right to file a written statement of disagreement with the denial. If you do not file one, you have the right to request that your request and my denial be attached to all future disclosures of your PHI. If I approve your request to amend your PHI, I will make the changes, tell you that I have done it, and tell others that need to know about the change to your PHI.<\/p>\n\n<p>F. The Right to Receive a Paper Copy of This Notice. You have the right to receive a paper copy of this notice even if you have agreed to receive it via email.<\/p>\n\n<p>V. HOW TO COMPLAIN ABOUT OUR PRIVACY PRACTICES<\/p>\n\n<p>If you think that I may have violated your privacy rights, or you disagree with a decision I have made about access to your PHI, you may file a complaint with me. You may also send a written complaint to the Secretary of the Department of Health and Human Services at 200 Independence Avenue SW., Washington D. C. 20201. I will not take retaliatory action against you if you file a complaint about my privacy practices.<\/p>\n\n<p>VI. EFFECTIVE DATE OF NOTICE.<\/p>\n\n<p>This Notice will go into effect on April 1, 2023. I reserve the right to change the terms of this notice. I will provide you with a revised notice as required.<\/p><\/div><div id=\"field_26_2\" class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_26_2' >Name of Group Participant:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_2' id='input_26_2' type='text' value='' class='large'   tabindex='5'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_26_3\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_26_3' >Parent\/Guardian Signature<\/label><div ><div id='input_26_3_Container' class='gfield_signature_container ginput_container' style='height:180px; width:400px; ' ><input type='hidden' class='gform_hidden' name='input_26_3_valid' id='input_26_3_valid' \/><canvas id='input_26_3' width='400' height='180'><\/canvas><\/div><\/div><\/div><div id=\"field_26_5\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_26_5' >Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_5' id='input_26_5' type='text' value='04\/30\/2024' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon' tabindex='6'  placeholder='mm\/dd\/yyyy' aria-describedby=\"input_26_5_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_26_5_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_26_5' class='gform_hidden' value='https:\/\/thechildandfamilyconnection.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_26_4\" class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_26_4' >Parent\/Guardian Signature<\/label><div ><div id='input_26_4_Container' class='gfield_signature_container ginput_container' style='height:180px; width:400px; ' ><input type='hidden' class='gform_hidden' name='input_26_4_valid' id='input_26_4_valid' \/><canvas id='input_26_4' width='400' height='180'><\/canvas><\/div><\/div><\/div><div id=\"field_26_6\" class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\" ><label class='gfield_label' for='input_26_6' >Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_6' id='input_26_6' type='text' value='04\/30\/2024' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon' tabindex='7'  placeholder='mm\/dd\/yyyy' aria-describedby=\"input_26_6_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_26_6_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_26_6' class='gform_hidden' value='https:\/\/thechildandfamilyconnection.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><\/div><\/div>\n        <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_26' class='gform_button button' value='Submit' tabindex='8' onclick='if(window[\"gf_submitting_26\"]){return false;}  window[\"gf_submitting_26\"]=true; 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}, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_26').val();gformInitSpinner( 26, 'https:\/\/thechildandfamilyconnection.com\/wp-content\/plugins\/gravityforms\/images\/spinner.svg' );jQuery(document).trigger('gform_page_loaded', [26, current_page]);window['gf_submitting_26'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}setTimeout(function(){jQuery('#gform_wrapper_26').replaceWith(confirmation_content);jQuery(document).scrollTop(jQuery('#gf_26').offset().top - mt);jQuery(document).trigger('gform_confirmation_loaded', [26]);window['gf_submitting_26'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_26').text());}, 50);}else{jQuery('#gform_26').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger('gform_post_render', [26, current_page]);} );} );\n<\/script>\n\n\t\t\t\t\t\t<h5 tabindex=\"0\">Electronic Communication Policy<\/h5>\n\t\t\t\n                <div class='gf_browser_unknown gform_wrapper gravity-theme' id='gform_wrapper_27' ><div id='gf_27' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_27' id='gform_27'  action='\/wp-json\/wp\/v2\/pages\/1078#gf_27' > \r\n <input type='hidden' class='gforms-pum' value='{\"closepopup\":false,\"closedelay\":0,\"openpopup\":false,\"openpopup_id\":0}' \/>\n                        <div class='gform_body gform-body'><div id='gform_fields_27' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_27_7\" class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\" ><h3 class=\"gsection_title\">Electronic Communication Policy for Psychoeducational Group<\/h3><div class='gsection_description' id='gfield_description_27_7'>Social Skills Group<\/div><\/div><div id=\"field_27_1\" class=\"gfield gfield_html gfield_html_formatted field_sublabel_below field_description_below gfield_visibility_visible\" ><p>In order to maintain clarity regarding our use of electronic modes of communication during your social skills group, I have prepared the following policy. The use of various types of electronic communication is common and many individuals prefer this method to communicate with others, whether it be for social or professional purposes. Many of these common modes of communication may put your privacy at risk and can be inconsistent with the law and with the standards of my profession. Consequently, this policy has been prepared to assure the security and confidentiality of your treatment and to assure that it is consistent with ethics and the law.<\/p>\n\n<p>If you have any questions about this policy, please feel free to discuss this with me.<\/p>\n\n<p><b>Email Communications<\/b><br>\nI use email communication and text messaging only with your permission and only for administrative purposes unless we have made another agreement. This means that email exchanges and text messages with my office should be limited to things like setting and changing appointments, billing matters and other related issues. Please do not email me about clinical matters as email is not a secure way to contact me. If you need to discuss a clinical matter with me, please feel free to call me at 949-221-4315. Telephone or face-to-face is a more secure mode of communication.<\/p>\n\n<p><b>Social Media<\/b><br>\nI do not communicate with, or contact any of my clients through social media platforms like LinkedIn, Instagram or Facebook. Adding patients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. In addition, if I discover that I have accidentally established an online relationship with you, I will cancel that relationship. If you have questions about this policy, please bring this up when we meet so we can discuss it.<\/p>\n\n<p><b>Fanning\/Following<\/b><br>\nYou may &ldquo;like&rdquo; The Child and Family Connection&rsquo;s Facebook or Instagram business page. However, the information on my page is often on my website as well. If you &ldquo;like&rdquo; The Child and Family Connection&rsquo;s page, you are choosing to reveal that you are connected to me in some way. My business page exists to be a forum of information and inspiration. I will not engage in conversations with you on that page. You are welcome to use your own discretion in choosing whether to follow my business page which may include business blogs and\/or newsletters. Please note that I will not follow you back. If there are aspects from your online life that you wish to share, please bring them into your appointments where we can view and explore them together during our therapy sessions.<\/p>\n\n<p><b>Websites<\/b><br>\nThe Child and Family Connection has a website you are free to access. I use it to provide relevant information as it relates to social skills groups and psychotherapy. You are welcome to access and review the information that is on our website and if you have questions about it, please let me know.<\/p>\n\n<p><b>Web Searches<\/b><br>\nI will not use web searches to gather information about you without your permission. I believe that this violates your privacy rights; however, I understand that you might choose to gather information about me in this way. At the present time, there is an incredible amount of information available about individuals on the internet, much of which may actually be known to that person and some of which may be inaccurate or unknown. 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