Application Page

Please follow the steps below:

Step 1: Complete and Submit Screening Forms

The two forms on this page are:

- Program Intake & Application Screener

- Parent/Guardian Consent & Participation Agreement

Step 2: Create your Rythmizo.org account

In order to purchase a plan and have access to the Member Portal, you will need to Sign Up and create your Rythmizo.org website account.

Step 3: Wait For Approval

Once your screening forms and account sign up are completed, your application is submitted and will be reviewed for approval.

Once approved, you will be able to log into the Rythmizo.org website, purchase a plan, and get access to the Member Portal and Rythmizo resources.

Program Intake & Application Screener

Thank you for your interest in the Rythmizo program.

This intake form helps us determine whether the program is an appropriate fit for you or your family. Rythmizo provides skills-based coaching and behavioral education and is not a therapy or crisis service.

All information provided will be used solely for the purpose of evaluating program eligibility and tailoring coaching support.

If you would like to complete this form on paper, please use this link to access/print this form and email your signed copy to contactus@rythmizo.com

Section 1 — Applicant Information

First name

Last name

Email address

Phone number

City/State

Are you completing this form as:

Parent/Guardian applying for a child

Young Adult applying for yourself

Section 2 — Parent/Guardian Information (if applicable)

Parent/Guardian Name:

Relationship to Child:

Phone Number:

Email Address:

Section 3 — Child or Participant Information

Participant Name:

Age:

Gender:

School (if applicable):

Current Grade Level:

Section 4 — Religious or Spiritual Background

Rythmizo works with families from many different belief systems. Understanding your worldview can help us communicate in ways that align with your values.

What religious or spiritual tradition do you identify with?

Examples may include:

Christian

Jewish

Muslim

Hindu

Buddhist

Atheist

Agnostic

Other

Please write your response below:

Section 5 — Behavioral Concerns

Please describe the primary behavioral concerns that led you to seek support.

Examples may include:

• impulsive behavior

• emotional outbursts

• difficulty regulating emotions

• family conflict

• defiance or authority struggles

• communication problems

Describe the primary challenges:

Section 6 — Behavioral History

Have there been any significant behavioral incidents in the past year?

Examples might include:

• aggressive outbursts

• property destruction

• physical altercations

• severe emotional breakdowns

If yes, please describe:

Section 7 — School Functioning

Is the participant currently experiencing difficulties in school?

Yes

No

If yes, please describe the challenges:

Examples:

• discipline issues

• academic struggles

• suspensions or expulsions

• difficulty with teachers or peers

Your Response:

Section 8 — Current Support Services

Is the participant currently receiving any of the following services?

Therapy or Counseling

Yes

No

Psychiatric Care

Yes

No

Medication for behavioral or emotional concerns

Yes

No

If yes to any of the above, please briefly explain:

Section 9 — Safety Screening

This question helps ensure that Rythmizo is an appropriate level of support.

Has the participant experienced any of the following within the past 12 months?

Suicidal thoughts

Yes

No

Self-harm behaviors

Yes

No

Thoughts about harming others

Yes

No

Psychiatric hospitalization

Yes

No

If yes to any of the above, please provide brief context:

Important Notice

Rythmizo provides coaching and educational services only and is not equipped to provide crisis intervention or mental health treatment.

If the participant is experiencing active suicidal thoughts or a mental health crisis, please contact emergency services or a licensed mental health professional immediately.

Section 10 — Motivation & Expectations

What led you to Rythmizo?

What are you hoping to gain from this program?

What changes would you most like to see?

Section 11 — Parent/Participant Commitment

Rythmizo is a skills-based coaching program that requires active participation.

Successful outcomes depend on:

• consistent practice of skills

• parental involvement

• willingness to implement structured strategies

Do you agree to actively participate in the program if accepted?

Yes

No

Section 12 — Acknowledgment

By signing below, you confirm that the information provided is accurate to the best of your knowledge and that you understand the purpose of this intake screening process.

Applicant Name

Date

Month

Day

Year

Signature

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If completing on behalf of a minor:

Parent/Guardian Name:

Date

Month

Day

Year

Signature

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Parent/Guardian Consent & Participation Agreement

This Parent/Guardian Consent Agreement (“Agreement”) is entered into between Rythmizo and the parent or legal guardian signing below (“Parent/Guardian”) for the participation of the minor child identified below in the Rythmizo coaching program.

If you would like to complete this form on paper, please use this link to access/print this form and email your signed copy to contactus@rythmizo.com

1. Purpose of the Program

Rythmizo provides skills-based coaching and educational resources designed to help families develop tools related to:

• emotional regulation

• impulse control

• communication

• behavioral accountability

• structured family systems

The goal of the program is to help parents implement structured behavioral strategies and skill-building techniques within the home environment.

2. Coaching Services — Not Therapy

The Parent/Guardian acknowledges and understands that:

Rythmizo does NOT provide:

• psychotherapy

• mental health treatment

• diagnosis of mental health conditions

• clinical counseling services

• crisis intervention services

• medical or psychiatric care

Rythmizo provides coaching and educational guidance only.

Participation in the program does not establish a therapist–client relationship or a medical relationship of any kind.

Parents are responsible for seeking licensed mental health or medical services if such services are needed.

3. Eligibility and Program Fit

Rythmizo is designed for families seeking skills-based behavioral coaching.

The Parent/Guardian confirms that, to the best of their knowledge, the participating child is not currently experiencing an active mental health crisis that requires professional treatment.

If a crisis situation occurs, the Parent/Guardian agrees to immediately contact:

• emergency services

• a licensed mental health professional

• a crisis support line

Rythmizo is not a crisis support service.

4. Parental Responsibility

The Parent/Guardian understands that:

• The program is designed to support parents, not replace parental authority.

• Parents remain fully responsible for decisions involving their child’s health, safety, discipline, and well-being.

• Implementation of skills and strategies is voluntary and at the Parent’s discretion.

Rythmizo cannot guarantee specific behavioral outcomes.

Results depend on consistent application of skills and family participation.

5. Participation of Minor Child

The Parent/Guardian grants permission for their minor child to participate in:

• coaching sessions

• group skill training sessions

• structured discussions

• skill-building exercises

Participation may occur through:

• live video sessions

• online platforms

• community forums

• downloadable program materials

The Parent/Guardian understands that online participation involves normal internet communication risks.

6. Confidentiality and Community Environment

Rythmizo may provide access to private member community discussions.

Participants agree to maintain a respectful and confidential environment.

However, the Parent/Guardian acknowledges that:

Rythmizo cannot guarantee confidentiality from other members participating in community discussions.

Parents are encouraged not to share sensitive personal information in group environments.

7. Appropriate Conduct

Participation in Rythmizo requires respectful behavior.

Rythmizo reserves the right to suspend or terminate participation if a participant:

• engages in harassment

• disrupts group sessions

• violates community rules

• creates a safety concern for other members

Membership termination decisions are at the sole discretion of Rythmizo.

8. Limitation of Liability

By signing this agreement, the Parent/Guardian agrees that participation in the Rythmizo program is voluntary.

To the fullest extent permitted by law, the Parent/Guardian agrees that Rythmizo and its representatives shall not be liable for any indirect, incidental, or consequential damages arising from participation in the program.

The Parent/Guardian assumes full responsibility for decisions made based on program materials or coaching guidance.

9. Emergency Situations

Rythmizo does not monitor participants for safety or crisis situations.

If a child expresses:

• suicidal thoughts

• intent to harm themselves or others

• severe psychological distress

the Parent/Guardian must immediately contact:

Emergency Services (911 in the United States) or a licensed mental health professional.

10. Acknowledgment of Understanding

By signing below, the Parent/Guardian confirms that they:

• have read this agreement in full

• understand the scope and limitations of the Rythmizo program

• understand that the program is coaching and education only

• consent to their child’s participation in the program

Parent/Guardian Information

First name

Last name

Relationship to Child:

Child’s Name:

Child’s Age:

Email

Phone

Agreement & Signature

I certify that I am the parent or legal guardian of the minor listed above and that I have the legal authority to provide consent for their participation in the Rythmizo program.

Date

Month

Day

Year

Parent/Guardian Signature:

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Rythmizo Representative (if applicable)

Name

Signature

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Date

Month

Day

Year

Step 2: Sign Up and Create Your Account

Sign Up