Please Select the Student's School* Kingsland Public Schools Pine Island Public Schools Rochester Alternative Learning Center Zumbro Valley Mental Health Center Parent/Guardian Consent Form Zumbro Valley Health Services will offer mental health care to students at Kingsland School District. Services will include care for a variety of mental health needs, along with the provision of chemical dependency evaluations. Services will be provided in individual, group, and family formats, depending on the student's individual needs. If a student has insurance coverage, a claim may be generated for the service that is provided at Kingsland School District. If a referral is made for more intensive services at Zumbro Valley Health Center offices, the student and parent will be required to do a formal intake with the Customer Service staff to initiate services. In order for your child to receive mental and chemical health care from the Zumbro Valley Health therapist, the following form must be completed and signed. Per MN statute 144.343, a minor may give consent for medical, mental, and other health services to determine the presence of or to treat pregnancy, and conditions associated with venereal disease, and alcohol and other drug abuse. Client Name* First Last Date of Birth* MM slash DD slash YYYY Gender* Male Female Address Street Address City State / Province / Region ZIP / Postal Code Phone Number*School ID Number Grade* Primary Clinic/Health Care Provider Your Name* First Last Relationship to Child* Date* MM slash DD slash YYYY Daytime Phone*Consent* I understand and consent to the following:By checking this box, you indicate an understanding that: • Kingsland School District may give information about the student’s health status (including access to school health records) as well as information about class schedule and attendance record to ZVHC personnel. • ZVHC personnel may exchange health information with the Kingsland School District staff and with other health care providers to whom the student may be referred for care, including but not limited to Mayo Clinic, Olmsted Medical Center and Rochester Students’ Health Services. All health information will be handled in a strictly confidential basis and in accordance with Minnesota data privacy laws. • One limit to confidentiality is if a student discloses information that would indicate an imminent danger to self or others. Additionally, if the student shares information pertaining to abuse or neglect, ZVHC staff is mandated to report the information to the Common Entry Point for abuse reporting. • Kingsland School District and Zumbro Valley Health Center may use student health records (while protecting student confidentiality) to evaluate the quality of care provided by Zumbro Valley Health Center. • A photocopy of this form is considered as valid as the original. • Permission will remain in effect until changed in writing by you or until the child reaches 18 years of age.If you have questions about this form or about the mental health services provided by Zumbro Valley Health Center please contact the Zumbro Valley Health Center main office at (507) 289-2089.Zumbro Valley Mental Health Center Parent/Guardian Consent Form Zumbro Valley Health Services will offer mental health care to students at Pine Island School District. Services will include care for a variety of mental health needs, along with the provision of chemical dependency evaluations. Services will be provided in individual, group, and family formats, depending on the student's individual needs. If a student has insurance coverage, a claim may be generated for the service that is provided at Pine Island School District. If a referral is made for more intensive services at Zumbro Valley Health Center offices, the student and parent will be required to do a formal intake with the Customer Service staff to initiate services. In order for your child to receive mental and chemical health care from the Zumbro Valley Health therapist, the following form must be completed and signed. Per MN statute 144.343, a minor may give consent for medical, mental, and other health services to determine the presence of or to treat pregnancy, and conditions associated with venereal disease, and alcohol and other drug abuse. Client Name* First Last Date of Birth* MM slash DD slash YYYY Gender* Male Female Address Street Address City State / Province / Region ZIP / Postal Code Phone Number*School ID Number Grade* Primary Clinic/Health Care Provider Your Name* First Last Relationship to Child* Date* MM slash DD slash YYYY Daytime Phone*Consent* I understand and consent to the following:By checking this box, you indicate an understanding that: • Pine Island School District may give information about the student’s health status (including access to school health records) as well as information about class schedule and attendance record to ZVHC personnel. • ZVHC personnel may exchange health information with the Pine Island School District staff and with other health care providers to whom the student may be referred for care, including but not limited to Mayo Clinic, Olmsted Medical Center and Rochester Students’ Health Services. All health information will be handled in a strictly confidential basis and in accordance with Minnesota data privacy laws. • One limit to confidentiality is if a student discloses information that would indicate an imminent danger to self or others. Additionally, if the student shares information pertaining to abuse or neglect, ZVHC staff is mandated to report the information to the Common Entry Point for abuse reporting. • Pine Island School District and Zumbro Valley Health Center may use student health records (while protecting student confidentiality) to evaluate the quality of care provided by Zumbro Valley Health Center. • A photocopy of this form is considered as valid as the original. • Permission will remain in effect until changed in writing by you or until the child reaches 18 years of age.If you have questions about this form or about the mental health services provided by Zumbro Valley Health Center please contact the Zumbro Valley Health Center main office at (507) 289-2089.Zumbro Valley Mental Health Center Parent/Guardian Consent Form Zumbro Valley Health Services will offer mental health care to students at Rochester Alternative Learning Center. Services will include care for a variety of mental health needs, along with the provision of chemical dependency evaluations. Services will be provided in individual, group, and family formats, depending on the student's individual needs. If a student has insurance coverage, a claim may be generated for the service that is provided at Rochester Alternative Learning Center. If a referral is made for more intensive services at Zumbro Valley Health Center offices, the student and parent will be required to do a formal intake with the Customer Service staff to initiate services. In order for your child to receive mental and chemical health care from the Zumbro Valley Health therapist, the following form must be completed and signed. Per MN statute 144.343, a minor may give consent for medical, mental, and other health services to determine the presence of or to treat pregnancy, and conditions associated with venereal disease, and alcohol and other drug abuse. Client Name* First Last Date of Birth* MM slash DD slash YYYY Gender* Male Female Address Street Address City State / Province / Region ZIP / Postal Code Phone Number*School ID Number Grade* Primary Clinic/Health Care Provider Your Name* First Last Relationship to Child* Date* MM slash DD slash YYYY Daytime Phone*Consent* I understand and consent to the following:By checking this box, you indicate an understanding that: • Rochester Alternative Learning Center may give information about the student’s health status (including access to school health records) as well as information about class schedule and attendance record to ZVHC personnel. • ZVHC personnel may exchange health information with the Rochester Alternative Learning Center staff and with other health care providers to whom the student may be referred for care, including but not limited to Mayo Clinic, Olmsted Medical Center and Rochester Students’ Health Services. All health information will be handled in a strictly confidential basis and in accordance with Minnesota data privacy laws. • One limit to confidentiality is if a student discloses information that would indicate an imminent danger to self or others. Additionally, if the student shares information pertaining to abuse or neglect, ZVHC staff is mandated to report the information to the Common Entry Point for abuse reporting. • Rochester Alternative Learning Center and Zumbro Valley Health Center may use student health records (while protecting student confidentiality) to evaluate the quality of care provided by Zumbro Valley Health Center. • A photocopy of this form is considered as valid as the original. • Permission will remain in effect until changed in writing by you or until the child reaches 18 years of age.If you have questions about this form or about the mental health services provided by Zumbro Valley Health Center please contact the Zumbro Valley Health Center main office at (507) 289-2089.HiddenEmail NameThis field is for validation purposes and should be left unchanged.
