Admin — Consent & Intake
BRIDGING SEASONS — ADULT SERVICE CONSENT (MASTER FORM)
1. Nature of Services
Bridging Seasons provides non-clinical peer support, consultation, and mediation-related support services. These services are designed to offer guidance, reflection, preparation, communication support, and structured conversations based on lived experience and supportive frameworks.
Services may include:
Peer support sessions
Consultation or preparation sessions
Mediation preparation (non-neutral support)
Virtual video sessions
Text-based support (when agreed upon)
These services are collaborative and supportive in nature and are intended to help individuals feel more grounded, prepared, and supported in moving forward.
2. Services Not Provided
Services through Bridging Seasons are:
NOT therapy or mental health counseling
NOT legal advice or legal representation
NOT medical or clinical care
NOT emergency or crisis services
If you are experiencing an emergency or crisis, please contact 988 or local emergency services.
3. Confidentiality & Limits
Your privacy is respected. Information shared during sessions is treated as confidential except in situations where disclosure may be required for safety or by law.
Limits to confidentiality may include:
Risk of serious harm to yourself or others
Suspected abuse or neglect where reporting is required under Nebraska law
Court order or other legal requirement
4. Virtual & Electronic Communication
Services may occur virtually using video, phone, email, or other electronic communication methods. Reasonable efforts are made to maintain privacy; however, electronic communication cannot be guaranteed to be fully secure.
By participating, you acknowledge and accept these risks.
5. Text-Based Support (If Applicable)
Text support, when offered, is:
Asynchronous and not live or immediate
Intended for supportive check-ins and reflection
Not appropriate for emergencies or crisis situations
Response times may vary and are not guaranteed.
6. Scheduling, Payments & Cancellations
Payment is expected within 24 hours of scheduling unless otherwise arranged.
Rescheduling requests should be made with at least 24 hours notice when possible.
Late cancellations or no-shows may be charged the full session fee.
7. Client Responsibility
Support services are collaborative. You remain responsible for your own decisions, actions, and how you choose to apply information or insights gained through services.
No specific outcomes can be guaranteed.
8. Voluntary Participation
Participation in services is voluntary. You may discontinue services at any time.
9. Consent
By signing below, you acknowledge that:
You have read and understand this agreement.
You understand the nature and limits of services provided.
You agree to participate voluntarily.
Full Name: _______________________________
Email: _______________________________
Phone: _______________________________
☐ I have read and agree to the information above.
Signature (type full name): _______________________________
Date: _______________________________
BRIDGING SEASONS — YOUTH SERVICE CONSENT (PARENT / GUARDIAN)
1. Nature of Services
Bridging Seasons provides non-clinical peer support, consultation, and supportive guidance services designed to help youth and families improve communication, emotional regulation, reflection, and preparation for challenges or transitions.
Services may include:
Youth peer support sessions
Parent or caregiver check-ins
Facilitated conversations between youth and caregiver when appropriate
Virtual video sessions
Text-based support (when agreed upon)
These services are supportive and educational in nature and are intended to help youth and families build communication, coping skills, and understanding.
2. Services Not Provided
Services through Bridging Seasons are:
NOT therapy or mental health counseling
NOT clinical mental health treatment
NOT legal advice or legal representation
NOT medical care
NOT crisis or emergency services
If your child is experiencing an emergency or crisis, please contact 988 or local emergency services.
3. Parent / Guardian Consent & Participation
Parent or legal guardian consent is required for youth services.
Parents/guardians understand that:
Support focuses on growth, communication, and skill-building.
Youth benefit from having supportive space to process and reflect.
Some information shared by the youth may remain private to support trust and development, except where safety concerns or legal requirements apply.
Parent or caregiver check-ins may be included as part of ongoing support.
4. Confidentiality & Limits
Privacy is respected; however, confidentiality has limits.
Information may be shared when:
There is concern for safety or risk of harm
Abuse or neglect is suspected and reporting is required under Nebraska law
Disclosure is required by court order or law
Parents/guardians acknowledge that safety always takes priority.
5. Virtual & Electronic Communication
Services may take place using video, phone, or electronic communication. Reasonable efforts are made to maintain privacy, but electronic communication cannot be guaranteed to be fully secure.
By participating, you acknowledge and accept these risks.
6. Text-Based Support (If Applicable)
Text support, when offered, is:
Asynchronous and not live or immediate
Intended for supportive check-ins and encouragement
Not monitored continuously
Not appropriate for crisis situations
Response times may vary and are not guaranteed.
7. Scheduling, Payments & Cancellations
Payment is expected within 24 hours of scheduling unless otherwise arranged.
Rescheduling requests should be made with at least 24 hours notice when possible.
Late cancellations or no-shows may be charged the full session fee.
8. Shared Responsibility
Support services are collaborative. Parents/guardians remain responsible for decision-making, supervision, and actions taken outside of sessions.
No specific outcomes can be guaranteed.
9. Voluntary Participation
Participation in services is voluntary. Parent/guardian or youth may discontinue services at any time.
10. Consent
By signing below, you acknowledge that:
You are the parent or legal guardian of the youth listed below.
You have read and understand this agreement.
You consent to your youth participating in supportive services through Bridging Seasons.
You understand the nature and limits of confidentiality.
Youth Name: _______________________________
Youth Date of Birth: _______________________________
Parent/Guardian Name: _______________________________
Parent/Guardian Email: _______________________________
Parent/Guardian Phone: _______________________________
☐ I have read and agree to the information above.
Parent/Guardian Signature (type full name): _______________________________
Date: _______________________________
BRIDGING SEASONS — TEXT SUPPORT ADDENDUM
1. Purpose of Text Support
Text-based support is offered as a supplemental service intended to provide brief check-ins, reflection prompts, grounding support, or supportive communication between scheduled sessions.
Text support is designed to complement — not replace — scheduled sessions or other services.
2. Nature of Communication
Text support is:
Asynchronous (not live or immediate)
Supportive in nature
Intended for brief communication and check-ins
Response times vary and are not guaranteed.
Typical response windows may range from several hours to 24–48 hours depending on schedule and availability.
3. Text Support Is Not Crisis Care
Text support is NOT:
Crisis response
Emergency mental health care
Continuous or on-demand communication
If immediate help is needed, please contact:
988 Suicide & Crisis Lifeline
911 or local emergency services
4. Boundaries & Expectations
By participating in text support, you understand that:
Messages may be responded to during business hours only.
Messages sent late at night or outside availability may be answered later.
Excessive messaging outside agreed package limits may require reassessment of support needs.
Communication must remain respectful and appropriate.
5. Privacy & Technology
Text communication carries inherent privacy risks. Reasonable efforts are made to protect confidentiality; however, electronic communication cannot be guaranteed to be fully secure.
By agreeing to text support, you acknowledge and accept these risks.
6. Package Structure & Limits
Text support operates within a defined monthly package that includes:
A set number of messages or check-ins
Defined response expectations
Any included video check-ins (if applicable)
Unused messages may not roll over unless explicitly discussed.
7. Modification or Discontinuation
Text support may be paused, adjusted, or discontinued if:
Boundaries are not respected
Communication becomes inappropriate for this format
Needs exceed the scope of text-based support
If this happens, alternative support options will be discussed.
8. Agreement
By signing below, you acknowledge that:
You understand the purpose and limits of text-based support.
You understand text support is not crisis or emergency care.
You agree to communicate within the expectations listed above.
Client Name: _______________________________
☐ I agree to the terms outlined above.
Signature (type full name): _______________________________
Date: _______________________________
BRIDGING SEASONS — MEDIATION INTAKE & AGREEMENT
1. Purpose of Mediation
Mediation is a voluntary, neutral process designed to help participants communicate, clarify issues, and work toward mutually acceptable agreements.
The mediator facilitates conversation and structure but does not make decisions for participants.
Participation is voluntary, and either party may choose to stop the process at any time.
2. Role of the Mediator
The mediator:
Remains neutral and does not take sides
Facilitates communication and problem-solving
Helps clarify concerns, goals, and options
Supports respectful dialogue
The mediator does NOT:
Provide legal advice
Represent either participant
Make decisions or impose outcomes
Guarantee agreements or outcomes
Participants are encouraged to seek legal or professional advice outside of mediation if needed.
3. Confidentiality
Mediation conversations are intended to be private and confidential to support open communication.
Limits to confidentiality may include:
Risk of serious harm to self or others
Suspected abuse or neglect where reporting is required under Nebraska law
Court order or other legal requirement
Participants agree not to record mediation sessions without mutual consent.
4. Mediation Process Structure
Mediation may include:
Individual intake sessions (one per participant)
Joint mediation sessions
Follow-up sessions as needed
Mediation focuses on communication, understanding, and problem-solving. Agreements reached are created by the participants.
5. Fees & Payment
Mediation fees are structured as follows:
$250 per party, which includes:
One individual intake session per participant (up to 1 hour)
Up to three (3) hours of joint mediation time
If additional mediation time is needed:
$60 per hour per party (prepaid prior to session)
Payment is expected within 24 hours of scheduling unless otherwise arranged.
6. Scheduling, Cancellations & No-Shows
Participants agree to provide at least 24 hours notice when possible for rescheduling.
Late cancellations or missed sessions may be charged in full.
Mediation may pause and resume at a later date based on remaining included time or additional scheduling.
7. Participant Responsibility
Participants are responsible for:
Participating respectfully
Making their own decisions
Seeking independent legal or professional advice when needed
The mediator does not guarantee outcomes or agreements.
8. Virtual Mediation & Electronic Communication
Mediation may occur virtually using video or electronic communication.
Reasonable efforts are made to protect privacy; however, electronic communication cannot be guaranteed to be fully secure.
By participating, you acknowledge and accept these risks.
9. Voluntary Participation
Participation in mediation is voluntary. Either party may request to pause or discontinue the process at any time.
10. Agreement & Consent
By signing below, you acknowledge that:
You understand the role and limits of the mediator.
You understand mediation is voluntary and neutral.
You understand the fee structure and expectations.
You agree to participate respectfully and in good faith.
Participant Name: _______________________________
Email: _______________________________
Phone: _______________________________
☐ I have read and agree to the information above.
Signature (type full name): _______________________________
Date: _______________________________
BRIDGING SEASONS — GROUP FACILITATION AGREEMENT
1. Purpose of Services
Bridging Seasons provides non-clinical group facilitation and supportive guided conversations designed to promote reflection, connection, communication, and personal or group growth.
Group sessions may include:
Guided discussion
Peer-support style facilitation
Skills-based reflection or structured exercises
Communication and relationship-focused support
Services are supportive and educational in nature and are not therapy, counseling, or crisis services.
2. Scope of Facilitation
The facilitator agrees to:
Provide structure and guidance for group conversation
Maintain respectful group flow
Encourage emotionally safe participation
Support constructive communication
The facilitator does not:
Provide therapy or clinical treatment
Provide legal or medical advice
Guarantee specific outcomes or group results
3. Group Structure
Group services will be provided as follows:
Group Name/Organization: _________________________
Session Format: (Virtual / In-Person / Hybrid)
Estimated Participants: _________________________
Session Length: _________________________
Frequency: _________________________
Start Date: _________________________
4. Responsibilities of Group Organizer
The group organizer agrees to:
Communicate logistics to participants
Ensure appropriate participant expectations
Provide a suitable meeting space (if in-person)
Maintain respectful group participation standards
The organizer understands that group dynamics may vary and participation is voluntary.
5. Fees & Payment
Group facilitation rates are determined based on:
Group size
Session length
Frequency
Preparation time
Travel or location considerations (if applicable)
Agreed Fee Structure: _________________________
Payment terms:
Payment due within 24 hours of scheduled sessions unless otherwise arranged.
Sessions may be canceled if payment is not received.
6. Rescheduling & Cancellations
24-hour notice is requested when possible.
Late cancellations may be charged in full.
Rescheduling will be based on facilitator availability.
7. Confidentiality & Group Expectations
Bridging Seasons encourages respectful confidentiality within groups; however:
Confidentiality between participants cannot be guaranteed.
Participants are encouraged to respect one another’s privacy.
Facilitator may intervene if safety concerns arise.
Limits to confidentiality may include safety risks or legally required reporting.
8. Virtual Sessions
If sessions occur virtually:
Participants are responsible for maintaining private spaces when possible.
Technology limitations may occur and are not guaranteed to be fully secure.
9. Liability & Expectations
Group facilitation provides structured support and guided conversation but does not replace professional therapy, crisis care, or legal services.
Participants and organizers remain responsible for their own decisions and actions.
10. Agreement
By signing below, the organizer confirms:
They understand the nature of group facilitation services.
They agree to the structure and payment terms outlined.
Participation is voluntary and collaborative.
Organizer Name: _________________________
Organization (if applicable): _________________________
Email: _________________________
☐ I agree to the terms outlined above.
Signature (type full name): _________________________
Date: _________________________