School Wellness Program Consent

To Parent(s) and/or Guardian(s):

Catherine’s Health Center and Kentwood Public Schools are partnering to provide Crestwood Middle School with a licensed, mental health provider and Registered Nurse. The School Wellness Program (SWP) protects and promotes student health and provides quality student-centered care. Healthy students learn better.

There is no cost for any SWP service. When available, insurance will be billed. 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 Catherine’s SWP services.
• Catherine’s 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.
• Catherine’s 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 referral or 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 services onsite, mental health counseling, treatment plan follow-up as prescribed by a physician, 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. Administration of over-the-counter medication Tylenol, Motrin, Zyrtec 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 limitd outpatient mental health services not to exceed 12 visits or four months and not to include any medications.

 

ALL STUDENTS WILL BE SEEN REGARDLESS OF ABILITY TO PAY. Insurance will be billed but students and families will not be expected to pay- out- of pocket costs.

 

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

Catherine's SWP Contact Sheila Jelsema at sjelsema@catherineshc.org 

(Note: If you do not select one, it will be assumed you are not seeking immediate therapy.)

I consent to all of the following:

• My child to receive services from the Catherine's SWP Registered Nurse and/or Licensed Mental Health Provider. I understand that:
  • 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 transitions out, or is discharged. 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 (all services, administration of OTC medications/physician directed standing orders, confidential risk assessment, immunization, mental health services including group therapy).

• That Catherine's 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 information from Kentwood Public Schools 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.
  • 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.

 

Health Services Consent Signature

1) I give consent for my child to receive services listed on the back of this form until age 18, or until my child leaves or graduates from school, or until my child transitions/is discharged out of care. I may withdraw my consent for services at any time upon written notice.

2) I may request a copy of the Catherine’s Health Center Notice of Privacy Practices and Patient Bill of Rights for both entities and a copy of the FTCA notice from Catherine’s Health Center

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

*The School Wellness Program is in partnership with Catherine's Health Center - catherineshc.org