Itinerant Mental Health Caregiver Request

Itinerant Mental Health Caregiver Request

In-person or telehealth services
Student Name

First NameLast Name
Student's School
Student's Grade
Caregiver Name

First NameLast Name
Caregiver Phone Number
Format: (000) 000-0000.
Caregiver E-mail
example@example.com
Name of Mental Health Provider (provider must meet qualifications per Minnesota Statute 2351.04)
Mental Health Provider Agency
Type of Service Requested
Caregiver Acknowledgement
By signing this agreement, caregivers are authorizing Minneapolis Public Schools to allow their student to meet with the above named provider at school. Caregivers understand that:
- Providers must complete the itinerant mental health provider agency agreement
- Approved providers must share a copy of the approved agency agreement with the school prior to visiting with students
- Meetings are limited to one hour visits one time per week
- Providers cannot observe or support students in their classroom.
- Agencies will have access to the student after MEA Break (October 19th, 2026).
Caregiver Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: