Student Mental Health Services Consent & Information

The Center Joint Unified School District (CJUSD) provides mental health services to students enrolled within the district. Please read this form carefully and provide all the requested information for your child to receive these free services at school.
The district may bill for these services through health insurance providers, but families will never have to pay any co-pays or deductibles. These are the exact same services CJUSD has already been providing; however, the district is now able to bill health insurance companies directly to help cover the costs. All money received from these insurance claims will be used exclusively to retain counselors, social workers, and therapists within the district to support students who request services.

CONSENT

I give permission for the Center Joint Unified School District to provide any of the services listed below, except as noted, to my child. This includes consent for any of the following, when advised or recommended by district staff:  
Health and wellness education  
Mental health services, including screening, assessment, and counseling  
Referrals for health services and linkage to services that cannot be provided at the school site 
Workshops (group) and peer support 

I understand my consent covers only those services provided at the Center Joint Unified School District. I understand that this consent form remains valid until one calendar year from the date signed or until we receive a written revocation.  I can change my mind later and decide I do not want my child to get services through the Center Joint Unified School District. If I change my mind, I will let the Center Joint Unified School District know in writing by emailing the school site administrator or sending a letter to the following address:  

Mike Jordan, CYBHI Administrator

8408 Watt Avenue

Antelope, CA  95843

I understand that I will not be billed directly for services provided by my district. However, the Center Joint Unified School District may seek payment from third parties, including my health insurance carrier, as a district billing under the Sacramento County Office of Education (SCOE). 
If insurance information is not provided, I consent to the Sacramento County Office of Education/Center Joint Unified School District, or its designee, searching statewide databases for active insurance.

Emergency Contact:  

Because this is a school-based mental health center, services are provided consistent with the school calendar. If you need emergency services when your provider is not available, please call 988, 911, or go to the nearest hospital emergency room. 

Confidentiality:  

I understand that by authorizing treatment at school, my child’s information is protected under the provisions of the Family Educational Rights and Privacy Act. My child’s information related to services received may be exchanged with school staff with a legitimate educational interest in order to assist with success in school, collaborate care, and evaluate the services provided. By signing below, I am consenting to the Center Joint Unified School District sharing information about services provided to my child, demographic information, and assessment information with third parties, including billing consortium leads and/or third-party payors, to seek reimbursement for services provided by the Center Joint Unified School District. I understand my child’s provider must share limited confidential information in the following circumstances:   

If the provider has good reason to believe that my child may harm another person or his/herself. 
If the provider has good reason to believe that a child, elder adult, or dependent adult is being abused or is being neglected. 
As otherwise required by law. 
 

 

Electronic Communication:  

If you decide to communicate with a staff member through electronic communications (i.e., text and unsecured/unencrypted email), the communication is not confidential, and there may be some risk that the information could be read by unintended recipients such as carriers, governments, and hackers. If you use electronic communications, you agree that the staff may reply with nonconfidential information that is responsive to the message and that the provider will only respond with confidential information in a more secure form of communication. Texts and emails should not be used for urgent or emergency situations. Your child’s provider may not be able to immediately respond to texts and emails.   

Notice to Families:

The Board of Behavioral Sciences receives and responds to complaints regarding services provided within the scope of practice of the Center Joint Unified School District Marriage & Family Trainees and associate social workers under the supervision of a licensed clinician. You may contact the board online at www.bbs.ca.gov, or call (916) 574-7830 if you have a complaint about the provider. The Director of Educational Services receives and responds to other complaints regarding wellness services by (district) To file a complaint, contact Mike Jordan at mikejordan@centerusd.org. 

Telehealth: 

I agree to receive health care services via telehealth (virtually) as needed. I understand:

I have the right to access covered services through an in-person, face-to-face visit or through telehealth.
The use of telehealth is voluntary, and I may withdraw my consent to, or stop receiving services through telehealth at any time without affecting my ability to access covered services in the future.
There may be limitations or risks related to receiving services through telehealth as compared to an in-person visit. For example, there is a risk that the technology may not work properly, and there is a risk to privacy if others may hear information discussed during the appointment if the location of the telehealth appointment is not private.

To conduct a telehealth appointment, I agree to the following: 

I agree to provide my email address 
I will secure a private location in which to conduct the appointment. If the telehealth provider has concerns that the best care may not be provided via telehealth, the provider may require that the student schedule an in-person visit.
For safety purposes, I will be asked to provide the address of my location before beginning the appointment. I understand I will be required to find another location if my provider does not feel my location offers the privacy and security needed. 
I understand the video session will not be recorded. 
I have read this document carefully, understand the potential limitations and risks of receiving services via telehealth, and have had my questions answered to my satisfaction.

I have reviewed the information in this form with the provider named below. 

My signature indicates that I understand the information in this form and freely provide my consent to receive services as outlined above. I will be informed of any risks and benefits associated with therapy and other services provided.