Concord School Wellness

JCHD SWP Consent Notification for Parents

To Parent(s) and/or Guardian(s): 

The Jackson County Health Department is partnering to provide Concord Schools with a licensed, mental health provider and Registered Nurse within the Concord School Wellness Program (SWP). The School Wellness Program protects and promotes student health and provides quality student-centered care.

Once consent is signed, you do not have to be present for your child to be seen.  

All students have the right to refuse or defer treatment unless there is reason to believe there is harm to self and/or harm to others. The student has a right to have any questions answered about their care. 

 I understand:

· That State law allows certain confidential services for students that meet age criteria*.

· My child has the right to refuse or defer treatment unless there is harm to self and/or harm to others.

· I am under no obligation to have my child utilize JCHD SWP services.

· Consents are valid until the student reaches age 18, the student leaves the district, or the consent is rescinded.

· JCHD SWP shall not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs, or disability.

· JCHD SWP will take reasonable steps to ensure that persons with Limited English Proficiency (LEP) and/or disabilities, including persons who are deaf, hard of hearing, or blind, or who have other sensory or manual impairments have meaningful access and an equal opportunity to participate in our services, activities, programs and other benefits.

No abortion services or counseling will be provided. No birth control pills or devices will be dispensed or prescribed according to Michigan Law.

·        I consent to the following:

· My child to receive services from the JCHD SWP Registered Nurse and/or Licensed Mental Health Provider. 

· Consent may be reviewed, and questions answered, before signing by a parent/guardian, minors, emancipated minor.

· This consent remains active until rescinded in writing, or when the student reaches age 18. Any student age 18 or older will sign the consent for services.

· Consent may be rescinded by the consented signed parent/guardian, minors, or emancipated minor. Discontinuation of services will be documented in the student’s chart. Other identified legal parent/guardian will be notified of discontinuation of services.

· JCHD SWP may:

· Exchange health information for continuity of care with my child's primary care physician.

· Obtain a copy of my student's immunization record.

· Exchange information for confidential internal peer audit or consultation with supervisor

· Use or disclose protected health information for treatment, payment, or healthcare operations.

· Collaborate and exchange student information with school officials/staff in order to improve services for students i.e.: chronic diseases and their care.

Parent consent is required for the following services to be provided if the student is under the age of 18:

· Nursing assessment, mental health counseling, medication administration, minor treatments and first aid following physician standing orders.

· Case management & chronic condition care and referrals.

· Individual or group health education.

· Confidential individual risk assessment – A copy of the risk assessment is located on our website

· Administration of over-the-counter medication

Parent consent is not needed for:

All students will be provided support in these areas:

· Emergency care/first aid.

· Crisis intervention including student:

· Is threatening suicide.

· Life is threatened.

· Is threatening harm to someone else.

· Has or intends to harm self.

· Student reports bullying others or reports being bullied

· Referral for 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: 

· Limited outpatient mental health services not to exceed 12 visits or four months and not to include any medications.

Health Services Consent Signature

1) I give consent for my child to receive services until age 18 or until the consent is otherwise withdrawn. I may withdraw my consent for services at any time upon written notice. 

2) I received a copy or may request a copy of the Jackson County Health Department's Notice of HIPAA Privacy Practices or viewed them at http://www.mijackson.org/hd under the document center section.