Perry Expanding & Enhancing Emotional Health Program/School Wellness Program Consent Form

Perry Expanding & Enhancing Emotional Health Program/School Wellness Program Consent Form
To Parent(s) and/or Guardian(s):

The Shiawassee County Health Department and Shiawassee Health and Wellness are partnering to provide Perry High School and Middle School with a licensed, mental health provider through the Perry Expanding & Enhancing Emotional Health (E3) Program. The program gives your child an opportunity to be seen by a licensed mental health provider without having to leave the school. You do not have to be present for your child to be seen. As of November 1, 2022, the E3 Program will be transitioning to a School Wellness Program (SWP). This consent will authorize continued mental health services to Perry students through this transition.

Your insurance will be billed for services provided by the E3 Program. If you do not have insurance, services will not be denied. The SWP will not bill insurance for services provided. Please contact us if you have any questions or concerns at the following number: 517-625-0009.

Crisis interventions and emergency care do not require consent. Life-saving interventions MAY be initiated without prior consent.

Current Michigan Law mandates (requires) confidential services to be available to minors in behavioral health counseling and substance abuse counseling. Michigan law allows for students 14 years or older to receive mental health services for up to 12 visits or over a 4-month period. After the 12th visit or 4 months, the mental health provider will terminate the service or notify the parent, guardian or person in loco to gain consent. Parental consent will be highly encouraged by staff throughout the process.

Sincerely,

Megan Allison, LMSW

I, the
Enrollment and Consent Form - Student Information
Student Full Name:*

First NameLast Name
Student Date of Birth:*

MonthDayYear
Date
Student Graduation Year:*
Student Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student Gender:*
Student Cell Phone:*
Please enter a valid phone number.
Student Email Address:*
example@example.com
Parent/Guardian Information

Birth Date is Required
Father of Student:

First NameLast Name
Father of Student Date of Birth:

MonthDayYear
Date
Father of Student Phone Number (Cell):
Please enter a valid phone number.
Father of Student Phone Number (Work):
Please enter a valid phone number.
Mother of Student Full Name:

First NameLast Name
Mother of Student Date of Birth:

MonthDayYear
Date
Mother of Student Phone Number (Cell):
Please enter a valid phone number.
Mother of Student Phone Number (Work):
Please enter a valid phone number.
Guardian of Student Full Name:

First NameLast Name
Guardian of Student Date of Birth:

MonthDayYear
Date
Guardian of Student Phone Number (Cell):
Please enter a valid phone number.
Guardian of Student Phone Number (Work):
Please enter a valid phone number.
Emergency Contact (Full Name & Phone Number):*

Student Health Information
Please list any medications that your student is currently taking and why:*
Does your student have a Primary Care Provider or Pediatrician?*

YesNo
Please provide the name of your student's Primary Care Provider or Pediatrician:
Does your student have another mental health provider?*

YesNo
Insurance Information

Policy holder date of birth is REQUIRED
What type of insurance does your child have?:

Private Insurance (Ex: Blue Cross)Medicaid ( Ex: Meridian Health, United Healthcare)None
Name of Insurance Company
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company Phone Number
Please enter a valid phone number.
Policy/ID Number:
Group Number:
Policy Holder Name:

First NameLast Name
Policy Holder Date of Birth:

MonthDayYear
Date
Place of Employment:
Please provide a copy of the FRONT of your insurance card:

Cancelof
Please provide a copy of the BACK of your insurance card:

Cancelof

Consent Form
I, the parent/guardian name of student name give consent for my child to receive services at the Perry E3 Program office and bill my medical insurance. I understand that this consent form is additionally valid for the School Wellness Program (SWP) or until I provide the clinic staff with written directions otherwise.

All healthcare information is confidential. If you wish for your child's behavioral health records to be shared with another healthcare entity, then a separate consent form must be signed. The document will be provided by the E3/SWP provider.

No student will be denied access to mental health services due to inability to pay. As in any clinic, there may be a charge depending on your insurance terms. When available, insurance or Medicaid will be billed. The health center may release information regarding treatment to third party payors for billing purposes.

Confidentiality between the student, parents,and the health clinic are assured. By law, some information requires the student's signed consent prior to disclosure to anyone, including parents/guardians. The staff will encourage every student to involve his/her parent/guardian in mental health decisions.

I understand that the E3/SWP provider will have access to my child's attendance and schedule to better serve my child during the school day. I give consent to Perry E3/SWP Social Worker to confirm my student's appointment date/time to relevant school staff to confirm the student's location during school hours.

I am the legal guardian of the above named child. I understand that if guardianship changes a new consent must be signed by the new guardian. I also understand that by providing an alternative contact, if I cannot be reached, medical information regarding the above-named child will be shared between the medical provider and the alternative contact.

Perry E3/SWP Program shall not deny benefits of, or discriminate against any individual/group because of race, gender, identification or expression, sexual orientation, partisan consideration, or disability or genetic information that is unrelated to the person's eligibility.
Signature of Parent/Legal Guardian *

Clear
Date*

MonthDayYear
Date
Perry E3 Program/SWP shall not deny benefits of, or discriminate against any individual or group because of race, sex, religion, age, national origin, color, height, weight, marital status, gender identification or expression, sexual orientation, partisan considerations, or a disability or genetic information that is unrelated to the person’s eligibility.
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Perry Expanding & Enhancing Emotional Health Program/School Wellness Program Consent Form

Enrollment and Consent Form - Student Information

Parent/Guardian Information

Student Health Information

Insurance Information

Consent Form