To Parent(s) and/or Guardian(s): 

The Shiawassee County Health Department and Shiawassee Health and Wellness are partnering to provide Perry High School and Middle School with a licensed, mental health provider and Registered Nurse within the Perry School Wellness Program (SWP). The School Wellness Program protects and promotes student health and provides quality student-centered care.

There is no cost for any Perry SWP service. Once consent is signed, you do not have to be present for your child to be seen. 

All students reserve the right to refuse care. The student has a right to have any questions answered about their care.

I understand:

• That State law allows certain confidential services for students that meet age criteria*.
• My child has the right to refuse or defer treatment unless there is harm to self and/or harm to others.
• I am under no obligation to have my child utilize Perry SWP services.
• Perry SWP shall not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability.
• Perry SWP will take reasonable steps to ensure that persons with Limited English Proficiency (LEP) and/or disabilities, including persons who are deaf, hard of hearing, or blind, or who have other sensory or manual impairments have meaningful access and an equal opportunity to participate in our services, activities, programs and other benefits.

Services NOT provided: NO birth control pill, or devices will be dispensed or prescribed. NO abortion counseling according to Michigan Law.

Parent consent is required for the following services to be provided if the student is under the age of 18.

• Direct health care onsite, mental health counseling, medication administration, minor treatments and first aid following physician standing orders.
• Case management participation and referrals if needed.
• Individual or group health education, confidential individual risk assessment and anonymous group assessments. Risk assessment questionnaire can be found here: RISK ASSESSMENT QUESTIONS
• Administration of over-the-counter medication (Tylenol, Motrin, antibiotic cream, anti-itch cream, antacid, cough drops)

*Current Michigan Law allows for confidential services to minor students in these areas.

12 years or older:

• Referrals and education regarding sexually transmitted diseases including HIV
• Referrals and education regarding family planning.
• Referrals and education regarding pregnancy care.
• Substance abuse counseling and referral

14 years or older:

• Can receive limited outpatient mental health services not to exceed 12 visits or four months and not to include any medications.

This program and materials were developed with state funds allocated by the Michigan department of Health and Human Services and Michigan Department of Education.

*Please provide any care plans associated with this diagnosis. This may include action plans, medical management school plans and any medications to be used in an emergency.

I consent to all of the following:

My child to receive services from the Perry SWP Registered Nurse and/or Licensed Mental Health Provider. 

• Consent may be reviewed, and questions answered before signing by a parent/guardian, minors, emancipated minor.
• This consent remains active until rescinded in writing or when the student reaches age 18. Any student age 18 or older will sign the consent for services.
• Consent may be rescinded by the consented signed parent/guardian, minors, or emancipated minor. Discontinuation of services will be documented in the student’s chart. Other identified legal parent/guardian will be notified of discontinuation of services.
• Services provided by the SWP requiring consent (nursing assessment, care coordination, first aid for minor injuries, administration of OTC medications, physician directed standing orders, confidential risk assessment, immunization, mental health services including group therapy).

Perry SWP may:

• Exchange health information for continuity of care with my child’s primary care physician.
• Obtain a copy of my student’s immunization record.
• Exchange information for confidential internal peer audit.
• Obtain student’s information for confidential care. Exchange of information will comply with all applicable laws e.g., HIPAA, FERPA and Michigan Statutes for governing minor’s rights to access consent for care. HIPAA notification will be given with consent form and made available for parent and student.
• Collaborate and exchange student information with school officials/staff on a “need to know basis” i.e.: chronic diseases and their care

Parent Consent is not needed for:

• Crisis intervention including student:
  • is threatening suicide
  • life is threatened
  • is threatening harm to someone else
• Has or intends to harm self
• Referral for suspicion of child abuse and/or neglect
• Emergency care/first aid

Shiawassee Health and Wellness occasionally works with interns who may be involved in your child's treatment. These individuals are overseen by licensed professionals.

1) I give consent for my child to receive services listed on the back of this form until age 18. I may withdraw my consent for services at any time upon written notice.

2) I received a copy or may request a copy of the Shiawassee County Health Department’s Notice of HIPAA privacy rules or view them at http://health.shiawassee.net under the Quick Links section.