Townline Consent

Student/Client Name

Date of Birth

Date

Sex

Insurance Provider

(Skip to "family size" if not insured)

Insurance #

Subscriber name (who pays for the insurance):

Subscriber DOB

Family Size (to help determine the sliding fee scale for other services at Catherine's)

Family Income

Parent/Guardian #1 Name

Parent/Guardian #1 Phone Number

Parent/Guardian #2 Name

Parent/Guardian #2 Phone Number

Is it okay to leave a voicemail on your phone?

Okay to text?

Email Address

example@example.com

Home/mailing address

Student/Client Race:

Student/Client Ethnicity:

LatinoHispanicNot Latino/HispanicOther

Home Language:

Current Housing Status:

I am looking for therapy to start:

as soon as possible, oras needed

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

Consent for Services

Catherine’s Health Center School Behavioral Health Program services may include behavioral and mental health assessment, treatment, individual therapy, and group therapy.
I understand that my child may be put on a waitlist depending on the number of openings in the clinician’s caseload, but that I can contact them at any time through the Godfrey office.
As a parent/guardian, I agree to play an active role in the process as requested by the clinician.
I understand it is not necessary to renew my consent yearly.
I understand I may withdraw my consent for services at any time upon written notice.
Minor children without a signed consent form on file will not be seen. Exceptions to this include under court-order; in the presence of a law officer when the parent cannot be promptly located.
I understand that no student will be turned away due to lack of insurance and all students will be seen regardless of their ability to pay. When available, insurance will be billed.
I understand that after therapy sessions begin, I have the right to withdraw my consent for treatment at any time and for any reason, however, I agree to make every effort to discuss any concerns about my child’s progress and/or other reasons for termination with my child’s provider prior to terminating.

What behavioral health concerns do you have about your child (Check any that apply)

Signature of Parent/Legal Guardian*

Date

CONSENT FOR TOWNLINE ELEMENTARY BEHAVIORAL HEALTH SERVICES