Client Information
CONSENT FOR TREATMENT
I, the undersigned parent/legal guardian, voluntarily consent for my child to participate in services provided by reSET Tomorrow, a behavioral health and youth development organization serving adolescents and children. I understand services may include, but are not limited to: - Mental and behavioral health counseling - Individual therapy - Group therapy - Family support services - Mentoring services - Case management - Therapeutic Behavioral Services (TBS) - Crisis intervention - Summer camp and after-school programming - Social emotional learning activities - Transportation assistance related to programming - Recreational and community-based activities I understand participation is voluntary and that I may withdraw consent for services at any time in writing unless otherwise prohibited by law.
Initials:______________
AUTHORIZATION FOR ASSESSMENT & CARE COORDINATION
I authorize reSET Tomorrow to complete behavioral health screenings, assessments, CANS assessments (when applicable), treatment planning, and care coordination services necessary to support my child’s emotional, behavioral, educational, and social needs. I understand information may be shared with: - Licensed clinicians - Medical providers - Schools and educational staff - OhioRISE care coordinators - Managed care organizations/insurance providers - Community support providers involved in treatment Such disclosures will be limited to information necessary for continuity of care and coordination of services in accordance with applicable confidentiality laws including HIPAA.
CONSENT FOR TRANSPORTATION
I authorize reSET Tomorrow staff to transport my child for approved program-related activities including: - School pick-up/drop-off - After-school programming - Community outings - Summer camp field trips - Recreational activities - Medical or behavioral health appointments when authorized I understand all reasonable safety precautions will be taken during transportation.
MEDIA RELEASE AUTHORIZATION (OPTIONAL)
I authorize reSET Tomorrow to use photographs, videos, or audio recordings of my child for promotional, educational, website, or social media purposes. I understand: - No confidential information will be shared. - Names may be omitted for privacy protection.
EMERGENCY MEDICAL AUTHORIZATION
In the event of a medical emergency, I authorize reSET Tomorrow staff to obtain emergency medical treatment for my child if I cannot be reached immediately.
CONFIDENTIALITY ACKNOWLEDGMENT
I understand all services provided by reSET Tomorrow are confidential except in circumstances required by law including: - Suspected abuse or neglect - Threats of harm to self or others - Court orders/subpoenas - Medical emergencies
FINANCIAL RESPONSIBILITY
I understand insurance information provided must be accurate and current. I understand I may be financially responsible for services not covered by insurance or funding sources.
PARENT/GUARDIAN ACKNOWLEDGMENT
I certify that: - I am the legal parent/guardian of the above-named child or otherwise authorized to consent to treatment. - I have read and understand this form. - I have had the opportunity to ask questions. - I voluntarily consent to services provided by reSET Tomorrow.
CLIENT ACKNOWLEDGMENT (IF APPLICABLE)
AGENCY REPRESENTATIVE
Staff reSET Tomorrow Date: May 26 2026
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