Application for Student Programs for Charlotte-Mecklenburg Schools Please enable JavaScript in your browser to complete this form.Student Name *FirstLastDOB: *Student Grade *School Name *Homeroom Teacher NameInsurance Company Name *Blue Cross Blue ShieldUnited HealthcareMedicaidAetnaCignaOtherPlease select your insurance below. Don't worry—this program is completely free for your family. Providing your insurance helps us keep it that way for everyone! If your plan is not listed, please select "Other" and a team member will contact you. Member ID (Policy Number) *Parent/Guardian Name *FirstLastParent/Guardian Email *EmailConfirm EmailParent/Guardian Phone *AddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeApplication for Student Programs for Charlotte-Mecklenburg Schools *Bridging Connections SEL GroupsBridging Connections Reading SEL GroupRe-entry ProgramFamily Engagement: Intensive In-Home ServicesMCV Residential Support100 Youth Council ProgramStudent Questionnaire Confidentiality Assurance: The information you provide in this intake questionnaire is strictly for our team at Concrete Roses Life Center. It will not be shared with CMS. Your responses are essential for us to conduct an assessment and create a tailored approach for your child, including selecting personalized books, journals, and other resources. How's your child behavior at home? Any behavior concerns in the school setting? * had your your How does your child express anger, sadness, and worry? *Is there anything specific that you would like to be addressed in regards to how your child behaves or manages their feelings? What are your child strengths? What are your child's interest/hobbies? *Has your child or family member ever been hospitalized for mental health issues? *Has your child had therapy in the past? What was the reason for attending therapy in the past? *Have your child ever attempted suicide or had thoughts about suicide? *Is your child taking prescription medication? If so, please list medication or dosage. *Who does your child live with? How is your child relationship with family members? *Who are important people in your child's life? *How is your child's relationship with peers? *How is your child academic performance? What are the goals you want for your child in the group? *Has your child experienced significant losses (grief-related)? *Has your child ever been physically, sexually, or emotional abuse? *Parent/Guardian Consent *I have read and understand the information above. I give permission for my child,I give consent for my child to work with the intern in a small group setting. I understand the intern is a trainee working under the direct clinical supervisionConsent for Billable Therapeutic Services: *YES, I give permission for the approved agency to use my child’s basic information to seek reimbursement through my insurance for the services described. I understand this is at no cost to me and is a condition of my child's participation.NO, I do not give permission for the agency to seek reimbursement through insurance. I understand this decision does affect my child's ability to participate in the program.Participate in school-based social-emotional learning (SEL) groups. Engage in services provided by an MSW clinical intern under supervision.”Signature * Clear Signature Custom Captcha * = Submit Application and Consent
