Participant ApplicationInterested in joining us at Donna Lexa Art Centers? Get started by filling out the application below!You can also print a hard copy of the application here and mail it to us. Questions? Contact us at programmgr@donnalexa.org or 262-521-2292. Student Name * First Name Last Name Date of Birth * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country My residence is a: * Family Residence Group Home Nursing Home Independent Living If group home, what is the group home name? Phone * (###) ### #### Confidential Communication Agreement: Can we call/leave a message on your phone? * Yes No Email * Is your home address the same as your billing address? * Yes No Billing Address (if different from Home Address) Address 1 Address 2 City State/Province Zip/Postal Code Country Billing Contact * First Name Last Name Billing Phone * (###) ### #### Legal Guardian (indicate SELF, if self) * First Name Last Name Legal Guardian Phone (if needed) (###) ### #### Preferred Studio location * Downtown Waukesha West Milwaukee Transportation Students need to provide their own transportation to and from classes. It is important for transportation to deliver and pick up as close to class time as possible. It is the student’s (or representatives) responsibility to coordinate transportation. Donna Lexa staff is not available prior to class time nor are they available to wait for late pick up after class. Please identify the type of transportation that will likely be used. * Private Vehicle Bus Curative Group Care Van Walk Metro Taxi Medicare Transportation Contact * First Name Last Name Transportation Phone * (###) ### #### Emergency Contact Emergency Contact: This person will be the contact in the instance of an illness or other issues that may arise during a class session. This person will also receive information about art center closings, upcoming events, art center news and classroom issues. * First Name Last Name Relationship * Emergency Contact Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact Phone * (###) ### #### Emergency Contact E-mail * Social Worker or Case Manager Name of Social Worker or Case Manager (if applicable) First Name Last Name Agency Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email General Information Place of Employment/School Employment/School Full-time Part-time Highest academic level reached? Are you a military veteran? Yes No What are your hobbies or interests? Medical Information Current Medical Doctor/Practitioner Doctor's Office Phone number (###) ### #### Known Allergies Known Dietary Restrictions What types of adaptive equipment are used? (For Example: wheelchair, walker, hearing aides, glasses, oxygen tank, etc.) Current Medical and Mental Health Conditions Past Medical and Mental Health Conditions What is the best way for you to receive instruction and assistance from others? Verbal Demonstration Written Step by Step Will initiate request for assistance Other Brief description of why you are choosing to participate in programs at Donna Lexa Art Centers: What goals or outcomes would you like to achieve at Donna Lexa Art Centers? (Ex: Artistic Skills, Social Skills, Self-Esteem, Etc.) What art materials are you interested in? PLEASE NOTE: We do not have the capacity to provide personal care such as assisted toileting. Our facilities are handicapped accessible but our staff is restricted to art instruction. They are not equipped to provide personal care. Please plan accordingly. STUDENT PARTICIPATION AGREEMENT: As an agency that employs art therapists and professional counselors in-training, we are governed by various laws and regulations and by a code of ethics. The Ethics Code requires that we make you aware of specific office policies and how these procedures may affect you. The Art Therapy Credentials Board (ATCB) oversees the ethical practice of art therapists and may be contacted with client concerns; 7 Terrace Way, Greensboro, NC 27403-3660, 877-213-2822. Please note that your individual provider may be an Art Therapist and a Professional Counselor in-training supervised by a licensed mental health professional and your group’s session content may be discussed with an outside supervisor. My (typed) signature below confirms that my rights as a participant/client have been explained to me, that I give my consent for art therapy, and that I have been given a copy of the Client Rights and Grievance Procedure for Community Services and Notice of Privacy Practices and that I have been provided with an opportunity to review it and discuss it with my provider. Student Name (typed) * Date * MM DD YYYY CLIENT RIGHTS AND GRIEVANCE PROCEDURE FOR COMMUNITY SERVICES AND NOTICE OF PRIVACY PRACTICES: Welcome to Donna Lexa Art Centers. We supervise undergraduate art therapy and art therapy/art education students, as well as graduate level student’s pursuing their master’s degree in art therapy. As such, we are governed by various laws and regulations and by the Art Therapy Code of Professional Practice, Art Therapy Credentials Board, 7 Terrace Way, Greensboro, NC, 27403-3660, 877-213-2822. The Ethics Code requires that we make you aware of specific office policies and how these procedures may affect you. Client Rights Your participation in our art therapy groups is strictly voluntary and you may leave the therapy relationship any time you wish. Please keep in mind that ending a therapeutic relationship can be difficult and closure is very important when moving on. Given this, we respectfully request that you give a minimum two weeks’ notice so we can conclude our therapeutic relationship on a healthy and positive note. Also, we will discuss your pertinent needs and therapeutic goals with an assigned legal guardian should you have one assigned to you. We will need applicable documentation on file noting your legal guardian. Limits of Confidentiality Sessions between art therapist and client are confidential, except under certain legally defined situations involving threats of harm to self or others, and situations of child abuse, elder abuse, or abuse of otherwise dependent individuals. In the case of danger to others, we are required by law to notify the police and to inform any intended victim(s). In the case of harm to self, we are ethically bound to inform the nearest relative, significant other, or to otherwise enlist methods to prevent harm to self or suicide. In instances of child abuse, elder abuse, or dependent abuse, we must notify the proper authorities. Participating in a group experience can be very rewarding, although in a group there is no absolute guarantee of complete confidentiality. Insurance At this present time, Donna Lexa Art Centers does not accept insurance. As such, we respect clients that are in financial need may require a reduced fee. The client must provide proof of need by completing the necessary form. The form must be approved prior to the group session, and be kept on file with Donna Lexa Art Centers. Telephone Accessibility & Emergency Protocols Should you need to contact an art therapist between sessions, he or she will return calls during the scheduled business hours, Monday through Thursday 9am – 3pm. We cannot guarantee an immediate returned call, although every effort will be made to return calls within a reasonable amount of time. If you have a life-threatening emergency, please call 911 for help. Payment & Fees Billing is prepared monthly and is payable upon receipt. A late fee may be charged for overdue payments. Two weeks’ advance notice of discontinuation or an extended planned absence is required. If a session is missed without prior notification, payment of session fee will be the responsibility of the participant or financial representative. Participants are expected to ensure, negotiate, or designate responsibility for fee payment in a timely and consistent manner. Questions regarding billing should be directed to the Business Office at 262-521-2292. My signature below indicates I understand these responsibilities and I agree to comply with all expectations and billing procedures. Appointments & Cancellation Policy Sessions are 2 hours long, unless a fee and time are agreed upon that supersedes the terms of a regular session. Occasionally, you may have to miss a group session, please notify Donna Lexa Art Centers as soon as possible, at least 24 hours in advance; if there is a 24-hour notice, you will not be charged. Agreement Acceptance I understand these responsibilities, and I agree to comply with all expectations and billing procedures. My typed signature indicates that I have read this agreement and understand its contents. Signature (typed) * Date * MM DD YYYY Thank you! We will contact you for next steps in the intake process!
