CBITS Bounce Back (rev 20221116) Cognitive Behavior Interventions for Trauma in Schools (CBITS)/ Bounce Back Participation Form Client Name* First Last Client Date of Birth* MM slash DD slash YYYY Is Client 18 or older?* Yes No Based on a recent screening of students we found that your child could benefit from Cognitive Behavior Interventions for Trauma in Schools (CBITS) group. We would like to offer your child the ten week group focused on helping him/her to express his/her thoughts and feelings about the stressful event(s) and lower the traumatic stress. As a part of the program, we will meet 1-2 times with your child for individual sessions, as well as the weekly in-person groups that will include peers from the school community. We will also schedule two parent meetings (via phone or telehealth) to give you any helpful information about your child’s progress and experience in the group. *This group can also be tailored to the developmental needs of younger children and is called Bounce-Back. By signing below, I understand and acknowledge the following I give permission for my child to participate in CBITS or Bounce Back group. If I have any questions about disclosure of my protected health information I may contact the agency Privacy Officer, Caitlyn E. Ogilvie, LCSW- 860-437-4550.Legal Guardian Signature (1)* Relationship to Client (1)* Legal Guardian Signature (2) Relationship to Client (2) Client Signature* Today's date* MM slash DD slash YYYY
