Please read the full Informed Consent, HIPAA and Professional Disclosure Statments and submit the form below with your electronic signature.

I hereby authorize the participation of my child listed in the form below for art therapy work with Lowcountry Autism Foundation’s (LAF) art therapist, Alyssa L. Millard, MAAT, ATR-BC, or another designated LAF art therapist. This consent is valid until rescinded by me, in writing.

I understand that myself or my child will receive group art therapy support in a group setting that is intended to help individuals to express, understand and address their needs as a child who has ASD or a caregiver or sibling of a child who has ASD, or some other developmental or intellectual delay. I understand that I am required to inform the art therapist of any of my or my child's major medical conditions, including, but not limited to, any allergies, managed or unmanaged seizures, visual impairment, mutism, profound hearing loss, or severe motor development, and understand that some of these conditions may affect the frequency, duration and effectiveness of the art therapy intervention that I or my child may receive. I understand that the purpose of this group is to address issues related to my needs for support as a caregiver of an individual with ASD, a sibling of a child with ASD or my child's needs for support as the individual with ASD or a developmental or intellectual delay.

I understand that these groups will be held in space or in a classroom that has been provided to LAF to use to provide these Art Therapy groups. I understand that others may be in the building at the same time LAF programs are taking place and I will not hold the owners of this space, LAF, Alyssa L. Millard, MAAT,ATR-BC, any employee or contracted service provider of LAF, LAF volunteer or any of the building’s staff, volunteers, or anyone associated with them liable for anything that may occur while I or my child is participating in LAF art therapy groups.

Worksheets, documentation and connections to resources will be provided within this group in order to foster further connections with other like-minded individuals as well as other support resources in the community. I understand that LAF , Alyssa L. Millard, MAAT, ATR-BC, any employee or contracted service provider of LAF, or LAF volunteer are not responsible for the way that these other resources are managed and I will not hold them, LAF or any volunteer, employee, board member or anyone associated with LAF, Alyssa L. Millard, MAAT, ATR-BC, liable for anything that may occur as a result of pursuing and participating in these resources suggested within this group.

I understand that LAF, Alyssa L. Millard, MAAT, ATR-BC, any employee or contracted service provider of LAF, or LAF volunteer are not liable for my or my child's progress and that not all individuals respond to art therapy as an intervention. I understand that I or my child will be using art materials and art tools (like scissors), which may stain my or my child’s clothing or with which an individual may injure themselves. While every effort is made to teach the safe and appropriate use of tools (like scissors), as well as art materials (like paint that may stain…your child will use an apron and have disposal latex free gloves to use) I understand that sometimes accidents may happen and I will not hold LAF, Alyssa L. Millard, MAAT, ATR-BC, any employee or contracted service provider of LAF, or LAF volunteer, liable if I or my child is injured in any way during these sessions. Alyssa L. Millard, MAAT, ATR-BC, any employee or contracted employee of LAF, or  LAF volunteer will provide assistance, as well as safety training around the use of these tools to make the use of these materials as safe as possible. I understand that Alyssa L. Millard, MAAT, ATR-BC and any employee or contracted service provider of LAF, or LAF volunteer has no control if I or my child refuse to take such help or follow the practices and techniques recommended and I will not hold LAF, Alyssa L. Millard, MAAT, ATR-BC, any employee or contracted service provider of LAF, or LAF volunteer liable if I or my child should injure themselves as a result of using these tools. Alyssa L. Millard, MAAT, ATR-BC, any employee or contracted service provider of LAF, or LAF volunteer will do their best to store any art materials or tools that could cause harm or injury if accessed freely (such as a scissors or glue gun) in an appropriate and safe way keeping them monitored at all times or out of reach and inaccessible when not being used. I will not hold LAF, Alyssa L. Millard, MAAT, ATR-BC, any employee or contracted service provider of LAF, or LAF volunteer liable if I or my child should access and use these materials without permission or supervision.

I understand that it is my and my child's responsibility to be sure that they remain respectful within the group and follow all of the rules of this group in order to participate. Alyssa L. Millard, MAAT, ATR-BC, any employee or contracted service provider of LAF, or LAF board member reserve the right to dismiss I or my child if we do not follow these group rules after all reasonable supports have been provided, or if the individual become a danger to themselves or others within the group. I understand that there are no cell phones allowed or they must be turned off during the session.

I understand that records of these sessions will be kept, that these records, as well as the art

work produced, are confidential as with any therapeutic relationship, and that LAF , Alyssa L. Millard, MAAT, ATR-BC, any employee or contracted service provider of LAF, or LAF volunteer need my written consent to release information of either written or verbal nature.

I understand that Duties to Warn, in other words, release without consent, is permitted if there is reason to believe that withholding such information poses a serious threat of harm to my child or others.

 I understand that pictures may be taken of myself or my child and their art productions as a part of the documentation of the session and any progress by my child. These images are a part of my and my child's confidential session and are to be kept confidential. If the therapist would like to use these images in a continuing education context or in research efforts, the therapist must obtain specific consent and release information from me, in writing. Should I chose not to sign said release, this will not affect in any way, the quality of services that my child is to receive.

 I also understand that Alyssa L. Millard, MAAT, ATR-BC, or any employee or contracted service provider of LAF involved in the group, may discuss aspects of their findings with the allied health professionals and qualified staff members of LAF in an effort to provide myself and my child with the highest quality services and support.

Furthermore, I understand that there may be one or two professionally trained volunteers hand-picked and verified (through a background check) as a reliable and trustworthy individual by LAF, present in every session. I understand that all staff members of LAF, Alyssa L. Millard, MAAT, ATR-BC, any employee or contracted service provider of LAF, or LAF volunteer are held accountable and are required to maintain the same ethics of confidentiality as outlined above.

Art Therapy HIPAA and Professional Disclosure Signature Page

To see Privacy Rule FAQs, you can go to http://answers.hhs.gov/cgi-bin/hhs.cfg/php/enduser/std_alp.php, then select “Privacy of Health Information/HIPAA” from the category drop down list and click the Search button.

Prior to your therapy, you will receive 1. An exact duplicate of this page, 2. The Professional Disclosure Statement, and 3. The Consent for Treatment for your personal records. It will be necessary for you electronically sign this certificate indicating that you have received, read and understand all documents. This certificate will be placed in your therapy file. Please do not sign the certificate if you do not understand any part of the HIPAA Client’s Rights, the Professional Disclosure Statement, and the Consent for Treatment.

Date *
Date
Child's Name *
Child's Name
Parent/Guardian Name *
Parent/Guardian Name
Electronic Signature *
Electronic Signature
Electronic Signature *