Military Adolescent School-Based Health Initiative

MILITARY ADOLESCENT SCHOOL-BASED HEALTH INITIATIVE

Consent for Services

The Military Adolescent School-Based Health Initiative (MASBHI) is a joint effort of the Puyallup School District (PSD), Madigan Army Medical Center (MAMC), and the Puyallup Community Based Medical Home (CBMH) designed to promote the physical, behavioral, and emotional well-being of military dependent adolescent students on their school campuses. The program is a response to recent national mandates, including the Army Family Covenant and the DOD Mental Health Task Force, calling for greater military and community collaboration on behalf of improving the quality of life for our nation’s warriors and their families.

WHAT IS A SCHOOL-BASED HEALTH CENTER? It is a comprehensive, primary care center located in a school. The staff includes pediatricians specializing in adolescent medicine, resident physicians, registered nurses, and administrative staff.

WHAT DO SCHOOL-BASED HEALTH CENTERS DO? School-Based Health Centers provide comprehensive physical, emotional and behavioral health care services such as diagnosis of acute minor illnesses and injuries, management of chronic illnesses such as asthma, immunization updates; screening for emotional and behavioral concerns, parent guidance, classroom consultation on wellness issues, and referrals to community providers as needed. Other complicated concerns may be referred for appropriate services at MAMC, or in emergency situations, to the Emergency Department co-located at MAMC.

HOW CAN A STUDENT USE THE HEALTH CENTER? A student must have a consent form signed by his/her parent or guardian in order to receive health center services. If the student is 18 years old or older or emancipated, he/she can sign his/her own consent form. The consent form is valid for the 2015-2016 school year and will be maintained at the school clinic for availability by the medical provider to ensure student eligibility for medical services. For complex medical decision making, parents will be notified by telephone during the clinical encounter in an attempt to provide feedback regarding their child’s current condition when appropriate. Also, parents have the option to be present during the clinical appointment at the schools. Appointments can be made by calling the MASBHI administrator at 253-477-5051. The MASBHI team will provide health services at Rogers High School on the every other Friday of the month from 0800-1130; starting January 2016. Parents or guardians may withdraw consent at any time in writing.

CONFIDENTIALITY: The MASBHI adheres to all current laws regarding confidentiality of health services in general and specifically as they relate to services to minors. Parental consent will not be required when state or federal law gives an Eligible Military Student Beneficiary the right to consent for services without such parental consent. The Notice of Privacy outlines how we may use and disclose your teen’s protected health information at MHS. All student information and documents maintained by the MASBHI will be handled by health center personnel only.

The PSD and MAMC are committed to maintaining a partnership that ensures easy access to health care for all eligible military associated students. By operating a health center on school grounds, MAMC accepts a unique responsibility to promote a safe and healthy school environment for all students. MASBHI staff will cooperate and communicate with the PSD staff whenever student behavior or health may result in risk of harm to the student or others within the educational setting. The MASBHI staff will follow policies and procedures developed by MAMC as well as those detailed in District board policies. Completing and signing the attached form authorizes the PSD to release and receive information as identified in the MAMC Privacy Notice.

I have read the above and understand the above statements. This consent expires June 30, 2016.

Signature______Date ______

Puyallup School District - MASBHI

SCHOOL-BASED HEALTH CENTER

PARENT PERMISSION FORM

Please complete all information on the front and back of this permission form. For your child to receive services from the School-Based Health Center, you must sign and date the form. If a student is 18 years old or older, he/she can sign his/her own permission form.

Student’s name: ______Male / Female

Last First Middle

Address:______City: ______Zip Code: ______

Home Phone: ______Birth Date:______Social Security:______Grade: ____

Mother or Father/ Guardian ______Work Phone ______

Cell Phone______Pager ______

Emergency Contact (Please provide the names of two adults to notify in an emergency, if you are not available.)

Contact name:______Phone:______Relationship______

Who lives with the Student (check all that apply):

Mother__ Father__ Step Mother__ Step Father__ Sister(s)__ Brother(s)__ Other______

Sponsor Social Security Number: ______

Where do you currently get your child’s medical care?

__ Community Health Center __ Hospital Clinic __ Other __Unknown

__ Emergency Room__ Military Clinic __ Private Doctor __Walk-in Clinic

__ Health Department Clinic __ Non-Regular Source __ School-Based Health Center

Name of child’s Primary Care Manager (PCM) ______

Date of last physical exam ______

Name of child’s dentist ______Date of last dental exam ______

Race:

__Hispanic/Latino __Black or African American__White

__American Indian/ Alaskan Native __Native Hawaiian/ Pacific Islander __Asian

__Unknown

Family Health History:

Please check below if any of your child’s BLOOD RELATIVES have had any of the following illnesses and indicate which relative had them:

Disease Relative Disease Relative

Diabetes ______Cancer ______

Heart Problem ______High Blood Pressure______

Anemia______Asthma______

Mental Illness______Alcohol/Drug Problems______

TB/HIV/AIDS______Death under age of 50______

Explanation______

August 2013

Puyallup School District - MASBHI

SCHOOL-BASED HEALTH CENTER

PARENT PERMISSION FORM

BASIC HEALTH AND BEHAVIORAL HEALTH SCREENING SERVICES AVAILABLE TO STUDENTS IN GRADES 6-12 AT SCHOOL-BASED HEALTH CENTER:

School Physical Exams Treatment of Asthma, Anemia, Acne, and

Nutrition and Weight Counseling Other Health Problems

Immunizations Referral for Specialty Care

Diagnosis and Treatment of Minor Behavioral Health Screening and Counseling

Illnesses/Injuries

Reproductive Health Management suchPregnancy prevention education and

as Sexually Transmitted Infection Screening contraceptive management as indicated

and Treatment as indicated

Does your child have a history of any of the following? (If yes, please explain):

1. Y N Allergy to food or medicine ______

2. Y N Taking medicine regularly ______

______

3. Y N Chronic health problem such as: asthma, diabetes ______

TB, heart disease, vision, hearing, dental or speech program ______

______

4. Y N Hospitalization, surgery, or major illness ______

5. Y N Significant injury or accident ______

6. Y N Has your child ever been referred for counseling ______

7. Y N Does your child have any emotional or behavioral problems ______

I have read the information supplied to me regarding the services of the School-Based Health Center and give permission for the above named student to use the services provided by the School-Based Health Center for as long as she/he is enrolled in the Clover Park School District.

I certify that the student is enrolled in Defense Eligibility Enrollment Reporting System (DEERS).

As the parent/guardian of the student identified above, I understand that I may revoke the permission at any time for any reason. I also acknowledge receipt of the School-Based Health Center Informational Sheet.

______

Signature (Parent/Guardian) Date

August 2013

MILITARY ADOLESCENT SCHOOL-BASED HEALTH INITIATIVE

Consent for Services

WHAT IS A SCHOOL-BASED HEALTH CENTER? It is a comprehensive, primary care center located in a school. The staff includes pediatricians specializing in adolescent medicine, resident physicians, registered nurses, and administrative staff.

WHAT DO SCHOOL-BASED HEALTH CENTERS DO? School-Based Health Centers provide comprehensive physical, emotional and behavioral health care services such as diagnosis of acute minor illnesses and injuries, management of chronic illnesses such as asthma, immunization updates; screening for emotional and behavioral concerns, parent guidance, classroom consultation on wellness issues, and referrals to community providers as needed. Other complicated concerns may be referred for appropriate services at MAMC, or in emergency situations, to the Emergency Department co-located at MAMC.

HOW CAN A STUDENT USE THE HEALTH CENTER? A student must have a consent form signed by his/her parent or guardian in order to receive health center services. If the student is 18 years old or older or emancipated, he/she can sign his/her own consent form. The consent form is valid for the 2015-2016 school year and will be maintained at the school clinic for availability by the medical provider to ensure student eligibility for medical services. For complex medical decision making, parents will be notified by telephone during the clinical encounter in an attempt to provide feedback regarding their child’s current condition when appropriate. Also, parents have the option to be present during the clinical appointment at the schools. Appointments can be made by calling the MASBHI administrator at 253-477-5051. The MASBHI team will provide health services at Rogers High School on the every other Friday of the month from 0800-1130; starting January 2016. Parents or guardians may withdraw consent at any time in writing.

I have read the above and understand the above statements. This consent expires June 30, 2016.

Signature______Date ______

PARENTS – Please keep this copy for your records