Student Name ____________________________________________ Birth date ______________________
Parent/Guardians Name_______________________________________________ Sex: Male Female
Contact Number__________________ Email Address___________________________________________
Grade_____________
Room_____________
School_________________
Teacher_____________
Address _________________________________________________________________________________
Street
City
State
Zip
ALLERGIES_____________________________ MEDICATIONS_________________________________
Ethnicity/Race: American Indian Asian/Pacific Islander Black/African American Hispanic
Middle Eastern/Arabic White/Caucasian Multi-racial Other Unknown
Doctor’s Name____________________________________ Doctor’s Phone number __________________
Does your student have any of the following (please check)?
Asthma
Yes No
Emergency plan at school? Yes No
Diabetes
Yes No
Emergency plan at school? Yes No
Epilepsy/Seizures
Yes No
Emergency plan at school? Yes No
Food allergy
Yes No Please list if applicable ___________________________________
List any Medical Illnesses (past/present)/Surgeries/Hospitalizations_______________________________
________________________________________________________________________________________
Eyes Glasses Contact lenses Date of last eye exam ________________________________________
Barriers to learning Vision Hearing Cannot comprehend Cannot read Language Barrier
Is there anything else we should know about your child’s health? ________________________________
________________________________________________________________________________________
Does your student have health insurance? None Medicaid Private_______________________
Insurance Carrier
Policy Number
Group Number
Policy Holder
Social Security #
Date of Birth
Would you like information on Insurers? Yes No
EMERGENCY CONTACT INFORMATION
Name: ______________________ Relationship to Child: _____________ Phone Number: ____________
Name: ______________________ Relationship to Child: _____________ Phone Number: ______________
The Life Center Complex, Inc.
1624 N Jessup Street, Lower Level • Wilmington, DE 19802
Phone: 302-552-3574 • Fax: 302-552-3561 • Email: [email protected] Website:
www.LifeHealthCenterDE.org
dba The Life Health Center
CONSENT FORM
I ____________________________give permission for my child _________________________
to be evaluated and treated at The Life Health Center in my absence. I understand that it may be
necessary to perform diagnostic tests (for example, a throat culture or blood test) in the course of
the evaluation. I accept responsibility for physician charges and laboratory fees.
Please CHECK services requested:
PHYSICAL HEALTH
 Assessment, diagnosis and treatment of minor illness and injury
 Physical examinations, including sports/employment/college physicals
 Immunizations in accordance with the Division of Public Health
 Screening for vision (including eye glasses)
 Screening for hearing, asthma, obesity, scoliosis, tuberculosis, and other medical
conditions.
 Medically prescribed laboratory tests, including diagnosis of acute and chronic illness and
disease, and dispensing and prescribing of medications.
 Dental examinations including: diagnosis, treatment, and sealants where available
 Nutrition services and referrals
 Annual health questionnaire
BEHAVIORAL HEALTH COUNSELING
 Evaluation and diagnosis
 Individual, Group or Family Counseling
 Drug, alcohol and other substance abuse counseling and referrals
 Referrals for long-term counseling or other evaluations
PLEASE NOTE THE FOLLOWING SERVICES ARE NOT COVERED AT THE WELLNESS CENTER:









Treatment or testing of complex medical or psychiatric conditions
Ongoing primary treatment of chronic medical conditions
Complex lab tests
Hospitalization
X-Rays
Condoms
Oral contraception to prevent pregnancy
Diagnosis and treatment of sexually transmitted diseases
HIV Testing and Counseling
The Life Center Complex, Inc.
1624 N Jessup Street, Lower Level • Wilmington, DE 19802
Phone: 302-552-3574 • Fax: 302-552-3561 • Email: [email protected] Website:
www.LifeHealthCenterDE.org
dba The Life Health Center
CONSENT FORM (cont.)
It is the Wellness Center's philosophy that parents/guardians should be involved in their child's care. Therefore, the
Wellness Center strongly encourages communication and involvement among students, parents and providers.
School-Based Wellness Centers are funded through state funds and reimbursement from insurance for those students
who have insurance.
The Division of Public Health (DPH) retains administrative authority for School-Based Wellness Centers.
Designated Wellness Team members are obligated by law to disclose specific patient information to DPH for the
purpose of preventing or controlling disease, injury, surveillance, or disability in Delaware and in the US.
Information that will be reported includes: sexually transmitted disease, laboratory data, births, deaths, adverse
medication reactions, child abuse or neglect, and domestic violence. Other general information may be sent to DPH
for statistical tracking, but this information will be de-identified during analysis, which means your son's/daughter's
name will be removed. Information about services may be shared with your health insurance company for purposes
of quality improvement.
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT
THE LIFE HEALTH CENTER SCHOOL BASED SERVICES
Effective April 14, 2003, the Wellness Center must comply with the Private Rules as detailed in the Health
Insurance Portability and Accountability Act (“HIPAA”). By law we are required to provide you with a copy of the
Wellness Center’s Notice of Privacy Practices. The Notice describes how the Wellness Center may use and disclose
health information about you that we have collected. It also explains how you can get access to this information.
The Wellness Center is committed to taking steps in compliance with applicable law, to protect your privacy and
confidentiality. We want you to know that we may use your health information for purposes of your treatment, to
obtain payment for services that we provide to you and for purposes of Wellness Center operations. For more
information on how we may use and disclose your health information, please read our Notice of Privacy Practices.
You may contact the Wellness Center staff to obtain the most current copy.
My son/daughter and I have read this form carefully and I understand that if I have any questions I may call the
Wellness Center Coordinator for more information before I sign this authorization.
By my signature below I agree, as the parent or legal guardian of the student named, or as an adult student that
 He/she may receive services at the School-Based Wellness Center (the “Wellness Center”)
 If my son/daughter has insurance I will provide this information to the Wellness Center.
 I understand that the Wellness Center will bill my insurance for covered services and it is my responsibility
to be aware of the terms and limitations of my insurance coverage.
 I understand that the School-Based Health Center may use telemedicine to provide mental health services.
The videoconference between student and mental health provider does not involve data storage, recording,
or archiving. Telemedicine encounters would still be subject to the requirements of the HIPAA Privacy
Rule that applies to Protected Health Information.
 This consent can be revoked in writing at any time, except to the extent that action has been taken in
reliance on this consent. Any requests for revocation must be in writing and sent to the Wellness Center.
_______________________________________________________
__________________________
Name of Parent/Legal Guardian
Date
_______________________________________________________
__________________________
Signature of Parent/Legal Guardian
Date
The Life Center Complex, Inc.
1624 N Jessup Street, Lower Level • Wilmington, DE 19802
Phone: 302-552-3574 • Fax: 302-552-3561 • Email: [email protected] Website:
www.LifeHealthCenterDE.org
dba The Life Health Center
ACKNOWLEGEMENT
OF HIPAA & GENERAL POLICIES
I acknowledge that I have received a copy of the following from LHC:
___ HIPAA Notice of Privacy Practices and
___ Counseling Practice Policies and Processes
I understand that after I have read these documents I may address any questions
to LHC. By signing below, I acknowledge having read, understood, and agreed to
these policies and processes.
____________________________________________________________
Client Signature
Date
____________________________________________________________
Parent/Guardian Signature (if applicable)
Date
The Life Center Complex, Inc.
1624 N Jessup Street, Lower Level • Wilmington, DE 19802
Phone: 302-552-3574 • Fax: 302-552-3561 • Email: [email protected] Website:
www.LifeHealthCenterDE.org
dba The Life Health Center
RELEASE OF INFORMATION
I, _____________________________________________________ (Parent/Guardian/or Adult Client), on behalf of
_______________________________________________________________ (Name of Client/D.O.B.), do hereby
authorize The Life Health Center vested staff/designees____________________________________________,
to ____disclose to and/or ____ obtain from: (Please include name address & phone number when applicable)
_____________________________________________________________________________________________
_____________________________________________________________________________________________
the following information: ___PHI and case data both qualitative and quantitative as deemed professionally
necessary by LHC vested staff/designees________________________________________
Purpose: Coordination of treatment services unless otherwise stated: ____________________________________
Revocation: I understand that I have a right to revoke this authorization, in writing, at any time. I further
understand that a revocation of this authorization is not effective to the extent that action has been taken in
reliance on the authorization.
Expiration: Unless sooner revoked, this consent expires one year from the following date: ___________________
Conditions: I further understand that LHC will not condition my treatment on whether I give authorization for the
requested disclosure. However, it has been explained to me that failure to sign this authorization may have
treatment continuity delays or otherwise adverse barriers to continuity of care.
Form of Disclosure: Unless you have specifically requested in writing that the disclosure be made in a certain
format, we reserve the right to disclose information as permitted by this authorization in any manner that we
deem to be appropriate and consistent with applicable law, including, but not limited to, verbally, in paper format,
or electronically.
Re-disclosure: State and Federal law prohibits the person or organization to which disclosure is made from making
any further disclosure of this information unless further disclosure is expressly permitted by the written
authorization of the person to whom it pertains. I understand that I have the right to inspect and copy the
information to be disclosed. I will be given a copy of this authorization for my records.
Signature of Patient/Client
Date
Signature of Parent/Legal Guardian
Date
The Life Center Complex, Inc.
1624 N Jessup Street, Lower Level • Wilmington, DE 19802
Phone: 302-552-3574 • Fax: 302-552-3561 • Email: [email protected] Website:
www.LifeHealthCenterDE.org
dba The Life Health Center