Alanson Wellness Program - Alanson Public Schools

Parent/Guardian/Adult Consent for Services
Full Consent:

Health Department of Northwest Michigan has partnered with Alanson Public Schools to provide a mental health professional and a registered nurse within the Alanson Wellness Program. The wellness program promotes student mental and physical health and provides quality client-centered care within the school.

Parents/guardians must provide consent for their minor children to receive services, with certain exceptions required by federal and Michigan law. Once consent for services is signed, you do not have to be present for your child to be seen. The consent is valid for the duration of your child’s current building of school enrollment, or if you choose to revoke parental consent.

SERVICES AVAILABLE
Our program is designed to provide connections to health care and community resources, a student health questionnaire (with consent), assistance with Medicaid insurance enrollment, and coordination of care with school and parents/guardians and primary care provider, with proper release of information.

Nursing:
- Care for minor injury and illness
- Administration of some over-the-counter medications
- Coordination for chronic disease management
- Assessment of immunization record, we will not administer immunizations.
- Referral to primary care, oral healthcare, specialty service or mental health providers
- Health education or counseling

Mental Health:
- Individual, family and group counseling
- Crisis intervention
- Coordination of care with school, parents/guardians, nurse, healthcare providers
- Referral to nurse
- Referral to outside mental health provider
- Telehealth sessions
- Assessments

Consent for Services Policy
Parents/Guardians must provide consent for their minor children for services at the school wellness program. Minors without written consent may receive one nursing service visit with verbal parent/guardian permission. Exceptions to this policy, required by federal and Michigan laws*, include emergencies threatening life or limb, and substance use services. Minors 14 years and older can obtain limited mental health services not to exceed 12 sessions or 4 months, without parent/guardian consent. The school wellness program can offer referrals, if applicable, without parent consent for certain confidential services, allowed by federal and Michigan laws, not directly offered by the school wellness program. People who are 18 or older, legally emancipated, legally married, under court-order, in the presence of a law officer when the parent cannot be promptly located and/or members of the U.S. Armed Forces provide consent for themselves.
School Health Privacy Practices
Student Health Questionnaire Policy

Health questionnaires give students and parents an opportunity to inform us about the students’ physical and mental health. The Health Department of Northwest Michigan (HDNW) offers the Student Health Questionnaire annually to all consented individuals.
Consent for Student Health Questionnaire

I consent to the completion of the Student Health Questionnaire annually while my child is enrolled in the current school building.
My child may complete the child version

My child may complete the child version Yes No
Parent/Guardian may complete the parent version

Parent/Guardian may complete the parent version Yes No
By signing this consent form, I certify that I am the parent/legal guardian of the student named below and give consent for the following services: (check one)

By signing this consent form, I certify that I am the parent/legal guardian of the student named below and give consent for the following services: (check one) Mental health AND nursing services Mental health services ONLY Nursing services ONLY
Student Information

Please complete the student's personal information below:
Student Name Student Name First Last
Preferred Name Preferred Name First Last
Date of Birth Date of Birth / MM / DD YYYY
Age
Gender

Gender Male Female Decline Other Other
Ethnicity

Ethnicity non/Hispanic Hispanic
Race

Race White/Caucasian Black/African American Native American Asian Multiple Other Other
Home Address Home Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Mailing Address Mailing Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Include only if address is different from home address.
Student Phone Number Student Phone Number - ### - ### ####
Student Email
Parent/Guardian Name #1 Parent/Guardian Name #1 First Last
Phone Phone - ### - ### ####
Relationship
Legal Custody

Legal Custody Yes No
Parent/Guardian Name #2 Parent/Guardian Name #2 First Last
Phone Phone - ### - ### ####
Relationship
Legal Custody

Legal Custody Yes No
Emergency Contact Emergency Contact First Last
Relationship
Phone Phone - ### - ### ####
Consent for Services

By signing this consent form, I certify that I am the parent/legal guardian of the student named above and give consent for my student to receive wellness program services. I agree that I have reviewed and understand the Consent for Services Policy and the school wellness program services available.

In addition, I acknowledge and consent that:

- This consent is valid while my child is enrolled at this current school building and I can withdraw my consent in writing, at any time.
- I understand that services can be refused or delayed at any time.
- All medical records are protected by the Health Insurance Portability and Accountability Act (HIPAA) and will only be released in accordance with the Health Department of Northwest Michigan (HDNW) confidentiality and release of information policy, which is available for review.
- HDNW may coordinate services or ongoing care with a primary care provider (PCP) only when a separate Release of Information (ROI) has been completed and authorized.
- HDNW staff may access school records or communicate with school staff for purposes such as attendance or to coordinate appointments for service
- Services, including certain confidential services, that meet age criteria, operate in compliance with federal and Michigan laws.*
- I have been given or have had the opportunity to review the HDNW Notice of Privacy Practices.

*Laws include Child Protection Law Act 238 of 1975, Civil Rights Act of 1991, Health Insurance Portability & Accessibility Act of 1996, Michigan’s Mental Health Code which includes minor consent, Public Health Code, Communicable Disease Rules, & Medical Records Access Act.
Today's Date Today's Date / MM / DD YYYY
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Student Insurance Information

Student Insurance Information No Insurance (Underinsured) Medicaid/Medicaid HMO Blue Cross Blue Shield Blue Care Network Priority Health Tricare Other Other
Policy Number
Policy Holder Name
Group Number
Policy Holder Birth Date Policy Holder Birth Date / MM / DD YYYY
Insurance Card

Attach Files
Relationship to Student
Contact me for information regarding

Contact me for information regarding Health Insurance Options Finding a Healthcare Provider Finding a Dentist Paying for medical bills Emotional wellbeing of child or adult in my home Paying for transportation to Healthcare Provider Help paying for heat/water/utility bills Shelter Food Clothing
Student Health Information

Allergy (medicine, food, environment)

Reaction/severity

Medication (prescription, vitamins)
Include Dose, Frequency, Prescribed by and Reason for Medication

Check if your student has had any of the following:

Check if your student has had any of the following: ADD/ADHD Autoimmune disorders Birth Defects Diabetes Developmental Disorders Developmental Disabilities Anxiety Depression Sleep Problems Abnormal Mood Swings Seizures Chest Pain Cognitive Impairment Unexplained Tiredness Blood disorder/cancer Unexplained Weight Gain/Loss Eating Concerns Stomach or Bowel Problems Head Injury Headaches Shortness of Breath/Asthma Head, Eyes, Ears, Throat Problems Blood Transfusions Anaphylactic Episodes Joint or Muscle Pain or Stiffness Physical/sexual/other trauma Other Other

Please describe anything checked above

Serious injuries or illness (describe)

Surgeries (reason/date)

Hospitalizations (reason/date)

Birth

Birth C-section Vaginal Premature Birth (# weeks) Premature Birth (# weeks)

Prenatal/Delivery Complications

Any trouble meeting developmental milestones? (i.e. speech, gross/fine motor):

Any trouble meeting developmental milestones? (i.e. speech, gross/fine motor): No Yes, please explain Yes, please explain

Student’s Doctor

Phone Phone - ### - ### ####

Student’s Dentist

Phone Phone - ### - ### ####

Alanson Wellness Program - Alanson Public Schools

Alanson Wellness Program - Alanson Public Schools

Parent/Guardian/Adult Consent for Services

Full Consent:

School Health Privacy Practices

Student Health Questionnaire Policy

Consent for Student Health Questionnaire

Student Information

Consent for Services

Student Health Information