Harrison Park Consent

Services provided include:

Physical exams for school, sports and camp
Treatment for acute, chronic illness and injuries
Vision / hearing screenings and followup and referrals
Immunizations
Basic laboratory services and tests
Crisis intervention
Administration of medication
Referrals for specialty services
Substance use education and counseling
HIV testing
Individual, group, family and community education
Mental health and psychosocial assessment, counseling and referrals
STD and screening checks
Pregnancy testing
Telehealth services/virtual visits

Services NOT provided include:

No birth control pills or devices are dispensed or prescribed
No abortion counseling, referrals or services provided

Patient/Student Name

School

Grade Level

Date of Birth

Date

Patient's Race (select all that apply):

Patient's Ethnicity (select all that apply):

What option best describes the patient's current living situation:

Other

Does the patient have health insurance?

Medicaid Number (if applicable)

Other insurance type, policy #, and name of insured parent (if applicable)

Note: Although insurance will be billed, there will be no copay or charge for services to the patient

Where did the patient previously go to see the doctor?

Doctor's office phone number:

Format: (000) 000-0000.

Date of the patient's last exam:

Date

List any allergies to medications, food, bee stings, etc.:

List current medications the patient is taking:

Patient's current pharmacy:

Does the patient have any medical problems including learning or physical disabilities?

If yes, please describe:

Any medical problems in the patient's family (siblings, parents, etc.)?

If yes, please describe:

Has the patient ever had to stay overnight in the hospital?

If yes, please describe:

Has the patient ever had any surgeries?

If yes, please describe:

Has the patient ever been hospitalized for a heart problem?

Parent/Guardian 1 name:

Date of Birth:

Phone number:

Format: (000) 000-0000.

Parent/Guardian 2 Name:

Date of Birth:

Phone Number:

Format: (000) 000-0000.

Patient's Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email address

example@example.com

Emergency contact name and phone number:

Household annual income:

# of people in household:

What language is most often spoken in your home:

Is there any other important information we should know?

Would you like to request any other assistance or have any comments to help the health center serve you better?

I consent for my child to receive MEDICAL CARE through the School Based Health Center at Harrison Park Academy. ***Please note: All required and recommended vaccinations will be given unless the parent or guardian complete the Vaccine Declination form.

I consent for my child to receive COUNSELING SERVICES and/or PSYCHIATRIC CARE (examples include 1:1 counseling, community resource referrals and outreach, coordination of outside resources/services, assessments, and medication reviews)

Note: PARENT CONSENT IS NOT NEEDED FOR CRISIS INTERVENTIONS SUCH AS:

If someone is threatening suicide
If a life is threatened
If someone is threatening to harm someone else
If someone has or intends to self harm
If emergency care/first aid is needed
If there is suspicion of child abuse and/or neglect

*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.

By signing this consent, I confirm I am the parent/legal guardian of the above listed student and am authorized to give this consent. I recognize that it is not necessary to renew my consent yearly but that I may withdraw my consent for services at anytime upon a written notice. 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

ParentGuardian Signature

Date

Harrison Park Consent

Services Provided

Basic Information

Health History

Parent/Guardian Information

Consent