Therapeutic Support Group:

for Parents of Individuals with

Down Syndrome

Carly Abel Counseling in Collaboration with DSAMT

Group Client Intake Form

The Group Counselor will follow up with you at the phone number provided after sign up to provide you the opportunity to ask any questions you may have about the group, and to ask you for some further information.

Online group counseling sessions will be scheduled Tuesday Evenings from 7:00-8:30pm

Name*

Address from which you will be attending the telehealth group sessions*

City, State and ZIP Code*

Email*

Home Phone Number*

Alternate Phone Number*

Age*

Emergency Contact Name*

Relationship*

Emergency Contact Phone Number*

Privacy of Your Health Information*

I, the undersigned, agree to the terms above.

Group Expectations*

I, the undersigned, agree to the terms above.

Consent for emergency*

I give consent to contact my identified emergency contact in the event of a psychiatric emergency situation.

I have read and agree to the terms above.

Contact Terms*

I give consent to be contacted by my therapist by phone and email and that it is acceptable to leave a voice message for me on the number provided.

I have read and agree to the terms above.

Consent for clinical treatment*

I give consent to my therapist, Carly Abel, MA, NCC, LPC-MHSP (Temp) to provide clinical treatment in the context of the group counseling relationship.

I, the undersigned, agree to the terms above.

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