Wellspring Center for Prevention has partnered with Carteret Junior High School to create and offer The PATH, School-Based Youth Services. The PATH Program provides 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 middle school years. The PATH provides counseling and programming such as clubs and groups that provide opportunities for healthy youth development.
I consent to have my child receive services provided by The PATH, Carteret’s School-Based Clinical Services Program. I further understand that clinical documents are confidential and may only be released with consent or at the professional discretion of The PATH employee. I understand that program attendance information and general updates will be shared with school personnel and program psychiatrist as needed. I understand that there are exceptions to confidentiality when disclosure is permitted or required by law. Any staff member not licensed as an independent practitioner is under the supervision of a qualified supervisor.
By sigining this form electronically, I consent to have my child receive services provided by The PATH, Carteret’s School Based Clinical Services Program.
I further agree to hold harmless Wellspring Center for Prevention/The PATH 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 your child is enrolled in Carteret Junior High School.
At times, The PATH Program will utilize various platforms to reach out to students; telephone, texting, email and video chat. By signing this form I am consenting to the use of such platforms. The PATH is utilizing HIPPA compliant platforms whenever possible, but electronic communication can never be guaranteed. The PATH 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 a PATH counselor may need to contact an emergency contact and/or appropriate authorities in the event of an emergency. If the student is not physically at school, I agree that my child will inform the counselor of the address where the child is physically located at the beginning of each session.
I acknowledge that The PATH 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 Protected Health Information is seen or overheard by others at the student's location, or if the student has 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. The PATH 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 The PATH 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.