Pathways SBYSP Consent Form

PATHWAYS, School Based Youth Services Program, has partnered with Carteret High School to create a safe and structured environment within the school to address the social, emotional and health needs of our students, ensuring that they are better able to be successful during and after their high school years. Pathways provides counseling and programming that provides opportunity for healthy youth development including clubs and groups.

I consent to have my child or myself (16y/o or older) receive services provided by PATHWAYS, Carteret’s School-based Youth Services Program. I further understand that clinical documents are confidential and may only be released with consent or at the professional discretion of the SBYSP employee, I understand that program attendance information and general updates will be shared with school personnel. I understand that there are exceptions to confidentiality when disclosure is permitted or required by law.

I further agree to hold harmless Wellspring Center for Prevention/The Pathways Program and its agents, staff and employees from any liability, provided Wellspring Center for Prevention has acted in good faith and according to agency policy and protocol.

This consent will be in effect for as long as you/your child is enrolled in Carteret High School and up to 1 year after graduation.

At times, Pathways will be using various platforms to reach out to students; telephone, email and video chat. By signing this form I am consenting to the use of such platforms. Pathways is utilizing HIPPA compliant platforms whenever possible, but electronic communication can never be guaranteed. Pathways staff will only communicate with students in a private setting and will not share the identity of their student through the use of their technology. I further understand that if I am/my student is using a Carteret issued laptop, the district can monitor any activity on that device. General emails, check ins and appointment communication may be done through unsecure means,ie email, Remind etc. I understand that there are risks and consequences associated with tele-counseling, including but not limited to, disruption of transmission by technology failures, interruption and/or breaches of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies.

I understand that my counselor may need to contact my emergency contact and/or appropriate authorities in case of an emergency. If not at school, I agree to inform my counselor of the address where I am at the beginning of each session.

I acknowledge that Pathways’ staff can only control technology security settings on their side of the communication, can only manage privacy in their environment, and is not responsible if my Protected Health Information is seen overheard by others at my location, or if I have not maximized the security features of our agreed-upon communications.
If participation includes group services: I also understand that participation in group services pose additional privacy and security risks as other group participants may not have taken the full steps necessary to help ensure confidentiality. Pathways’ staff will review group privacy and security requirements with all participants and remove members who cannot adhere to these requirements if this information becomes known; however, staff may not know of all potential risks at each group member’s location

** Important – all students may be seen by Pathways staff for a screening or crisis intervention session one time at the discretion of school personnel or at student request to resolve immediate concerns or provide evaluation. Any future interventions will require consent.

**In 2016, the Boys and Girls Clubs Keystone Law was passed, which empowers youth 16 and older to consent to treatment services on their own, without separate authorization from a parent or legal guardian.

I Consent to All Services Provided By Pathways SBYSP*

YesNo

Please identify any services that you do not consent to below

I grant permission for my/my child's photograph or image to be used for program promotion or educational purposes.*

yesno

I grant permission for my/my child to participate in the “Child and Youth Resilience Measure and the impact survey. (anonymous satisfaction survey) More information is available about these tools at your request. These tools are utilized to evaluate the effectiveness of school based programming and no results will be connected with your/your child’s name.*

yesnonot a high school student

Name of student*

First NameLast Name

Student Cell

Please enter a valid phone number.

Date of Birth*

Date

Student's Grade*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent Name*

First NameLast Name

Parent Phone Number - best number to reach you*

Please enter a valid phone number.

Parent Phone Number - alternate number*

Please enter a valid phone number.

Parent Email

example@example.com

Emergency Contact*

First NameLast Name

Emergency contact phone number*

Please enter a valid phone number.

Does your child get free or reduced lunch*

yesno

Primary language spoken at home

Would you like a counselor to reach out to you or your child regarding counseling sessions?*

YesNo

If yes was answered above, please provide the preferred phone for contact

Please enter a valid phone number.

If you have requested a counselor reach out to you or your child, please tell us a little about why

Signature*

**Please call Ediza Lahoz, PATHWAYS Director at 732-541-8960 Ext: 4304 or 732.543.5040 (Pathways Cell) if you have any questions or concerns. If your issue is not resolved please call Ezra Helfand, Executive Director of Wellspring Center for Prevention at 732.254.3344.

Pathways School Based Youth Services Program