Behavioral Healthcare
Cass
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Dodge
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Douglas
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Sarpy
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Washington
Young People’s Peer Support Group
Permission Slip
The Young People’s Peer Support Group is a peer run group for young adults who have
experienced difficulty with mental health or substance use. This group provides a unique place
to for young adults, ages 16-26, to come together, get to know one another and use personal
experiences to offer strength, support and suggestions to other group members. Group is held
every 2nd and 4th Tuesday of the month from 3:30pm-5:00pm at Region 6 Behavioral Healthcare
3801 Harney Street Omaha, NE 68131.
Please complete this permission slip to authorize this young adult under the age of 19 to
attend and participate in the Peer Support group offered by Region 6.
I,
__________________________________, am the parent/legal guardian of
___________________________, and give my permission for him/her to attend the
Young People’s Peer Support group offered by Region 6 Behavioral Healthcare.
By signing below, I authorize this youth’s participation in the Young People’s Peer Support
groups offered by Region 6 Behavioral Healthcare.
By checking this box, I authorize Region 6 to transport this youth to and from the Peer
Support Group, including use of a third party transportation agency.
Signature: _________________________________
Date: ____________________
Please submit this permission slip
to TRY Coordinator
(p) 402-996-8193 (F) 402-444-7722
aweaver@regionsix.com
or at the group.
Emergency Contact Information:
Name:
Phone Number:
Address:
3801 Harney Street
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Omaha, NE 68131-3811
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Relationship:
Phone: 402-444-6573
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FAX: 402-444-7722
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1-800-311-8717
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www.regionsix.com