• Psycho-educational Group Disclosure and Consent Form

  • DOB*
     . .
    2 digit month, 2 digit day, 4 digit year
  • 0/100
  • 0/200
  • I have currently or in the past planned/intended to/ or attempted death by suicide*
  • Joining Group For
  • My connection to ADHD*
  • My connection to ADHD (Minors only)*

  • Consent

    * required

  • I agree to be added to the email list for the purpose of major group change announcements, links to meetings, and simple updates.

  • I attest that the information here is accurate, complete and about myself. I agree to adhere to the norms and expectations for group therapy as indicated above. I acknowledge that I have had the opportunity to ask questions and such questions were answered clearly and to my satisfaction.
  • Clear
  • Clear
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • **Your information will not be shared, sold, rented, or lent to anyone now or in future. The information you provide is protected by HIPAA. All information will be deleted at end of year.**

  • Clear
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty:
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