Participant Application

Please fill out and submit the online application below.  If you want to submit a hard copy application please print, fill out, and mail in the Participant Intake Form

Online Participant Application Form

  • Personal Information

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  • Please indicate SELF if you are your own guardian.
  • 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.
  • 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.
  • Social Worker or Case Manager

  • General Information

  • Medical Information

    Please describe any special medical issues that Donna Lexa Community Art Centers, Inc. staff will need to know to most effectively work with the applicant.
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  • PLEASE NOTE: We do not have the capacity to provide 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.

    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 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.

    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 signature indicates that I have read this agreement and understand its contents.
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