MPS Itinerant Mental Health Provider Agency Agreement

MPS allows Itinerant Mental Health services in the school setting when there is an educational benefit for the student, as determined by parent and school staff. All services must be provided by a licensed mental health professional as defined by Minnesota law.

Below is an agreement that overviews responsibilities for MPS and the Itinerant Mental Health Provider Agency (Agency) regarding services provided to students in MPS buildings.

        Policies, Liability and Safety

• Agency will conduct criminal background checks on all staff who have direct contact with MPS students on MPS property in accordance with MPS policy.
• Agency will maintain comprehensive general liability insurance, including coverage for death, bodily or personal injury, property damage, and liability coverages, with limits of not less than $1,500,000 each claim and $1,500,000 each occurrence.   Agency may meet the limits above $1,000,000 per occurrence through umbrella/excess coverage. 
• Agency will comply with all MPS policies and state/federal laws regarding student data privacy.
• Agency must immediately notify Judy Brown judy.brown@mpls.k12.mn.us of any investigations, disciplinary action, or disruptions in licensure of any employee who actively meets with a student in an MPS building (including virtually).  
  

  Consent to Meet with Student

• Caregivers must initiate a request for services prior to clinicans meeting with students. Caregivers must initate this process; MPS staff will not obtain this consent on your behalf.
  • Caregivers must initiate a new request for services for any provider changes, even within an organization.
  • Consent forms are valid for the current school year only.
• If student data is needed, agency must obtain caregiver consent to access private student data and follow MPS processes.

  Scheduling Meetings with Students
  

• Agency staff will provide the following when requesting to meet with student in school:
  • Copy of this signed Agency Agreement
  • Valid Photo Identification 
• Agency staff will follow each school’s process for requesting to meet with a student; meetings should take place at a time and frequency directed by School Staff and should not significantly interfere with a student’s educational program.
• Meetings are limited to one hour visits and one time per week.
  

  Responsibility
  

• Agency understands that it is not hired by MPS; no MPS funds are used for payment to see students.
• Agency understands that this Agreement must be renewed annually and that MPS has the right to revoke this agreement at any time.
• Agency must use district supported video conferencing tools for telehealth services. Telehealth services are only available for secondary students.
  
  

  Terminating Access
  

• MPS reserves the right to terminate meeting access without notice or cause to any individual as deemed necessary.
• If an Agency employee is deemed to be a risk or threat, the Agency must immediately contact MPS Emergency Management & Safety at 612-668-0322.

By signing this agreement, Agency agrees to follow the processes and guidelines outlined above.   Authorized Agency signer will share a copy of this signed agreement with individual providers who are covered under the agreement.

Note: A copy of your completed form will be emailed to you upon submission.  Please ensure that your employees/representatives have a copy of the completed form as they will be asked to show it when they check in at a school building or before beginning virtual services.