Kids in Divorce Registration

Kids in Divorce - Intake Sign-up Packet

Family Orientation Questionnaire
Family Agreement Form
Seven Exceptions to Privacy
Your Rights to Privacy and Exceptions to Privacy

The same parent needs to attend with their child/children each week. We take forms on a first-come, first-served basis. Once we receive your form, we will confirm that you have a reservation in the group.

"*" indicates required fields

FAMILY ORIENTATION QUESTIONNAIRE

Parent/Guardian's Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number*

Email*

Emergency Contact*

First Last

Emergency Contact Phone*

Names & Ages of Kids Attending*

Any Family Allergies? – Please List Here

How Did You Hear About Kids In Divorce?

Check Which One Applies*

Recently Separated

Divorce Is In Process

Divorce Is Final

If Divorce Is Final, What Is the Length of Time You've Been Divorced?

Please Explain Extended Custody Arrangement

Any Special Needs or Concerns You Want to Share About Yourself or Your Children?

FAMILY AGREEMENT FORM

Before completing and signing this form, please read and discuss with the adults, children and teens who want to participate at Kids in Divorce. 1. We understand that Kids in Divorce provides support groups, not therapy or counseling. 2. We agree to attend our group regularly. We agree to call when we are unable to attend our group. 3. We agree that a child or teen must always be accompanied and supervised by a parent or another adult. We agree to always have a parent or another adult remain at Kids in Divorce while the child or teen is in a group. The same parent needs to attend the adult group each week. Ex-spouses are welcome to attend another session, but not the same session. 4. We have read and understand the Family Agreement Form. We have discussed this information and agree to abide by the guidelines of Kids in Divorce.

Family Agreement Signature*

I Accept (Electronic Signature Agreement)*

I Decline to Sign

*Electronic Signature Agreement. By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement.

Today's Date*

SEVEN EXCEPTIONS to PRIVACY

Exception #1 – Texas law requires our staff to report to the appropriate government agency any suspected physical, sexual, or emotional abuse or neglect.

Exception # – If we learn that someone with whom we are working has a specific intent to bring harm to him/herself, we reserve the right to inform other family members and/or make appropriate referrals if necessary.

Exception #3 – If we have reason to be concerned about the drug and/or alcohol use or abuse by a child or teen, we reserve the right to inform the parent.

Exception # – If information is ordered by the court, including a subpoena, we will attempt to contact you about the order. If you oppose the release, the court may nevertheless require compliance with the order.

Exception #5 – If we learn that someone participating in the program might commit a violent act, we may take steps to protect the intended victim against such danger or inform police, or both.

Exception #6 – The rights and exceptions to privacy apply to information disclosed in support groups. All group members are encouraged to keep such information confidential, but Kids in Divorce cannot guarantee they will do so.

Exception #7 – At times, Kids in Divorce uses case examples of children or teens and their families in publishing articles, conducting professional training, community education, and in fund raising efforts. We may anonymously refer to your situation in those circumstances. Your child, teen or family’s complete name will never be used without your specific written approval.

YOUR RIGHTS TO PRIVACY AND EXCEPTIONS TO PRIVACY

Our work with you and your family at Kids in Divorce is confidential. Information shared with the staff, volunteers and other participants is private. Your rights to privacy will be strictly maintained. There are, however, some important exceptions to privacy which are explained on the back.

Please Read the Seven Exceptions to Privacy Above Before Signing Below

In signing this document, I acknowledge that I have had the opportunity to ask questions about Kids in Divorce Confidentiality Policy. I have read and understand the “Right to Privacy and Exceptions to Privacy” information. I fully understand and accept my rights to privacy and the exceptions to rights to privacy.

Rights to Privacy and Seven Exceptions Agreement*