PATHWAY TO PROGRESS SCHOOL BEHAVIORAL HEALTH PROGRAM
Your child has the option to participate in the Pathway to Progress School Behavioral Health Program which is a confidential process designed to help address concerns, come to a greater understanding of his or herself, and learn effective personal and interpersonal coping strategies. It involves a relationship between the student and the Therapist who has the desire and willingness to help the student accomplish their individual goals. Pathway to Progress School Behavioral Health Program involves sharing sensitive, personal, and private information that may at times be distressing. During these conversations, there may be periods of increased anxiety or confusion. The outcome of these conversations is therapeutic, often positive; however, the level of satisfaction for any individual is not predictable. Your Therapist is available to support the student throughout the Pathway to Progress School Behavioral Health Program process.
All interactions with Pathway to Progress School Behavioral Health Program Services, including the scheduling of and/or attendance at appointments, content of your child's sessions, progress in sessions, and your child's records are confidential. You may request in writing that your child's Therapist release specific information about your Pathway to Progress School Behavioral Health Program sessions to person(s) you designate.
EXCEPTIONS TO CONFIDENTIALITY:
By signing this consent form, you agree to give On Site Counseling authorization and/or its authorized representative or third-party advocate to request copies of mental health/psychiatric medical records, billing records, and/or utilization management determination records relating to the child named herein above. This authorization is in compliance with the provisions of HIPPA (Health Insurance Portability and Accountability Act) and GLB (Gramm Leach Bliley Act).
This consent also grants On Site Counseling and/or its authorized representative or third-party advocate authorization to pursue an appeal and/or request a State Fair Hearing related to any denials of care, health plan coverage, or payment by the child’s designated health plan provider. Further, this authorization grants permission to On Site Counseling to request a Provider Directory from insurance company on behalf of child/member named above.
I, , have read the above information. I understand the risks and benefits of the program, the nature and limits of confidentiality of the services from On Site Counseling. I understand that the signing of this form does not guarantee participation in the Pathway to Progress School Behavioral Health Program.
Name of Parent / Tutor / Administrator / Student, if 18 years or older:
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Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: CONSENT FORM
Agree & Sign