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Behavioral Health Online Consents (English)

Our commitment to keeping you safe

We have never taken for granted the sacred trust you place in us to care for your child, and today we are more grateful than ever for that privilege. To learn about all the ways we are working to keep you, your family and our team members safe, visit our COVID-19 updates page.

Learn More about our commitment to keeping you safe
Learn More about our commitment to keeping you safe

Behavioral Health Online Consents

In order to receive services, you must first be referred by a participating school counselor or primary care provider. Please speak with your child’s school counselor or primary care provider to determine if they are participating in this program. Prior to receiving services, a parent or guardian must complete and submit the appropriate forms below. Once the forms have been received by our team, you will be contacted to set up your child's appointment. If you have questions, please call 844-856-6926.

School Referral Package

For families referred by their participating school counselor.

  1. Consent for Initial Screening: provides consent for the first telephonic parent screening and case management support with a licensed behavioral health clinician.
     
  2. Demographics form: provides information to create the telebehavioral health medical record in Children’s Health electronic medical records.
     
  3. Release of Information: provides consent to share behavioral health information with school personnel.

School Referral Package


Clinic Referral Package

For families referred by their participating primary care provider.

  1. Consent for Initial Screening: provides consent for the first telephonic parent screening and case management support with a licensed behavioral health clinician.
     
  2. Demographics form: provides information to create the telebehavioral health medical record in Children’s Health electronic medical records.

Clinic Referral Package


Treatment Package

For families who will receive in-person or virtual health therapy services.

  1. General Consents: provides consent for virtual and in-person services and acknowledgement of exchange of health information and financial responsibility for billed services.
     
  2. Consent for Treatment: provides consent for individual or family therapy with a licensed behavioral health clinician

Treatment Package


Consent for Treatment

Provides consent for individual or family therapy with a licensed behavioral health clinician

Consent for Treatment


Release of Information (ROI)

To be filled out by all families as needed.

Release of Information: provides consent to share behavioral health information with referral sources or other parties as indicated.

Release of Information

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  • School Based Telebehavioral Health FAQ
  • Behavioral Health Online Consents (English)
  • Behavioral Health Online Consents (Spanish)
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