Families Group Counseling in Nature Fall 2025

Client Registration Information
Parent Name*

First NameLast Name
Parent's Middle Initial
Parent's Date of Birth*

MonthDayYear
Date
Parent's Age
Parent's Preferred Name/Nickname
Parent's Race and Ethnicity*
White, Hispanic, Black, American Indian, Multiple Races, etc.
Parent/guardian Email Address*
example@example.com
Parent/guardian Contact #*
Whose Number? (ex. Parent's Cell, Mom's Work, Youth's Cell)
Primary Address*

Address

Street Address Line 2

CityState

Zip
Name of School(s) Youth Enrolled In*
Family Information
Parent Guardian Information (Please provide information for each parent or guardian, including stepparents, to help us better understand the client's family situation).
Youth Information (please provide information about each child in the family to help us better understand the client's family situation).
Who all will be participating in groups from the tables above?*
Are there any concerns such as food allergies (in case we bring snacks), diagnosed or suspected mental health issues, suicidal thoughts or behaviors, anger management, etc. the counselor should be aware of?
If there are concerns about mental health issues, have they been formally diagnosed? If yes, please provide the date of diagnosis and history of treatment services.
Are there other topics you would like to see covered in future sessions/groups?
This could include future groups for youth, parent educational sessions, etc.

Parent/Guardian Consent Form
Your permission is requested for your family to receive group counseling at Riveredge Nature Center with the Youth and Family Project (YFP). YFP offers free, confidential counseling services to youth in need of support and their families. If your permission is granted, your family will be matched with a masters-trained mental health counseling provider.

Counselor: Jordan Markiewicz, LPC-IT

E-mail: jmarkiewicz@YouthAndFamilyProject.org

Because counseling is based on a trusting relationship between counselor and client, the counselor will keep information shared by the client confidential except in certain situations in which an ethical responsibility limits confidentiality. It is important to the therapy process that he/she does not think the parent and the therapist are conspiring against him/her in any way. There are times when students divulge information that should be shared with parents. The counselor will encourage them to do so or request permission to discuss the matter with a parent or guardian. This will be done when the counselor feels it is in the best interest of your son or daughter. As mandated reporters, there are also several situations in which YFP counselors are required by law to share details of a counseling session with the appropriate authorities. These situations include:
- Situations in which the counselor believes that the student is a threat to himself/herself or others
- When the communications involve information regarding child abuse, child neglect, or abuse of the elderly
- When the communications involve information regarding inappropriate sexual contact with a minor child
- When the client becomes a litigant in a court proceeding
- When the counselor discusses case work with his/her individual and/or group supervisor
By signing this form, I give my informed consent for my family to participate in counseling. I understand that anything that my family shares will be kept confidential except in the above-mentioned cases.
I understand that through participating in this program, my child will be spending time in nature and walking on uneven terrain in a variety of weather conditions. There is also potential for encounters with wildlife such as insects like mosquitos or ticks. I acknowledge that there are inherent risks associated with this activity and my child's participation is voluntary. As such I assume all risk and release the Youth and Family Project and Riveredge Nature Center from liability for any resulting injuries or damages.*

I assume all risk for participation and release the providers of any liability.
Parent/Guardian Signature*

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Date

MonthDayYear
This consent will be on file throughout the time that your child participates in services. You may revoke this consent at any time. Please feel free to call if you have questions, comments, or concerns, 262-338-1661 (Emily Greene, Executive Director).
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Introduction

Client Registration Information

Family Information

Parent/Guardian Consent Form