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CONSENT FOR BEHAVIORAL HEALTH SERVICES
PLEASE READ BEFORE YOU SIGN
 
 
 
 
 Date of Birth: 

 

Big Sandy Health Care is now providing Behavioral Health services for students in the Martin County schools. These services include assessments to determine the need for counseling and the provision of counseling to students. By signing and dating this document, I am authorizing and consenting for my child to have an assessment performed by a Big Sandy Health Care-employed Therapist or Counselor. I further authorize Big Sandy Health Care’s Therapist or Counselor to meet with my child during the school day to provide Behavioral Health counseling services.

I understand that Big Sandy Health Care must follow all laws on patient privacy and confidentiality. Each state has exceptions to laws on privacy and confidentiality when the safety and wellbeing of a person is in question. Under such exceptions, reports to a third party are required. Big Sandy Health Care Therapists and Counselors are required by law to make a report to a third party for safety reasons when they are presented with statements and other surrounding circumstances that involve any of the following: the abuse of a minor child; the abuse of a senior citizen or dependent adult; domestic violence and/or domestic abuse of spouses; a patient who has threatened the safety, wellbeing or life of another person; and a patient who has threatened to harm himself/herself or take his/her own life.

I hereby authorize and consent for my child to receive Behavioral Health services at his/her school from a Big Sandy Health Care employed-Therapist or Counselor. I further authorize and consent for my child’s Big Sandy Health Care Therapist or Counselor to share information about my child, on a need-to-know basis, with school personnel. I understand that I can terminate Behavioral Health services and revoke this consent, in writing, at any time. I understand that if I want Big Sandy Health Care to provide treatment information about my child to anyone other than school personnel, I will have to authorize and consent, in writing, to release information.

I give my permission for Big Sandy Health Care Inc., through its Therapists and Counselors, to provide Behavioral Health services to my child, who is listed above.

 

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