Kannapolis City Schools

Kannapolis City Schools

School-Based Mental Health Services Agreement

Mental health is directly related to children’s learning and development. To ensure a safe, healthy environment for all KCS students, we recognize the need for school-based mental health services, including those provided by outside agencies as well as those provided by qualified school-based staff. KCS desires to facilitate the provision of school-based mental health services by outside providers, in a manner that will minimize disruptions to the educational environment. For the benefit of our students, KCS therefore has developed this collaborative agreement with outside mental health providers regarding the provision, integration and coordination of mental health services in our schools. Please review these terms carefully and submit the completed agreement to Skylia Solomon in student services for approval. All parties must sign this agreement before school-based services can be provided. Once signed, an individual school-based mental health plan must be completed for each student receiving services and kept on file at the school level.

Agency: ______

Address: ______

______

Agency Contact: ______

Phone: ______Email: ______

School-based services provided: ______

Attach the following to this agreement:

c  Copy of certification/licensure

c  Certificate of liability insurance

c  Copy of parent/guardian consent to services and exchange of information

By signing this agreement, the agency agrees to develop individual student mental health services plans and to coordinate the scheduling of all appointments with the designated school contact. The agency will schedule appointments during non-instructional times when possible and will avoid unscheduled visits. The agency will notify the designated school contact in advance of cancellations. The agency also agrees to follow proper building check-in and check-out procedures for each scheduled appointment. The agency understands that failure to adhere to these conditions may result in termination of the agreement and subsequent discontinuation of school-based services by the agency. The agency also understands that this agreement must be submitted annually and it is the responsibility of the agency to notify the school district of any changes to information submitted.

Agency Representative (print) ______

Signature: ______Date: ______

KCS Student Services Representative: ______Signature: ______Date: ______