SBHC Consent to Treat Form ONLY English/ Spanish Version

Form
School Based Health Center Consent Form
Student Name*

First NameLast Name
Student Date of Birth*

MonthDayYear
Date
Social Security Number
School District*

Carroll CountyGrayson CountyGalax City SchoolsFloyd CountyPatrick County
Name of School Student Attends *
Medical Services Provided:
- Physical exams for school, sports and camp
- Treatment for acute and chronic illness and injuries
- Vision/Hearing screenings and follow-up
- Referrals for specialty Services
- Basic Laboratory Services and Tests
Behavioral Health Services Provided:
- Talk Therapy to address mental health concerns
- Tools for improved emotional regulation, coping skills, and social skills
- Referrals for specialty care
I consent for my child to receive care through the School Based Health Center.*

YesNo
Signature*
Date*

MonthDayYear
Date
Should be Empty:

Form