If you would like your child to participate in the Life Health Center School Wellness Program, please complete pages 1-5.

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1 If you would like your child to participate in the Life Health Center School Wellness Program, please complete pages 1-5. Student Name of Birth Sex: Male Female Address Street City State Zip Grade Room School Teacher What is your child s ethnic background? White/Non-Hispanic Hispanic: Mexican Puerto-Rican Cuban Dominican Other Black/African-American Middle Eastern or African American Indian Asian/Pacific Islander Multi-racial Other It is the Wellness Center's philosophy that the doctor should speak to the parent/guardian in order to provide the best possible care to the child. What is the best way to talk to you during school hours? Name Home phone number Cell phone number Work number address Best Language? Parent #1 Parent #2 English Spanish Other English Spanish Other

2 Please tell us about your child s health: Does your child have a regular doctor? Yes No Doctor s Name Doctor s Phone number Is your child allergic to penicillin? Don t know Is your child allergic to any other medicine? Don t know Is your child allergic to any food? Don t know Please list all the other medicines and foods your child is allergic to: Please list any medicines that your child takes every day: (please add more paper if needed) Name of Medicine How much What time does your child take the medicine Does your child have any of these medical problems (please check)? Asthma Emergency plan at school? Diabetes Emergency plan at school? Epilepsy/Seizures Emergency plan at school? Food allergy Emergency plan at school? ADHD Autism Eczema Sickle Cell Disease Obesity Emotional or Behavioral problems? None Yes Other medical condition(s)? None Yes Does your child wear glasses? No Yes of last eye exam? Is there anything else you would like us to know about your child?

3 CONSENT FORM I give permission for my child to be evaluated and treated at the Life Health School Wellness Eisenberg. Please check each box below to show that you understand: I understand that: You will call me every time that you see my child. If you cannot reach me, you will treat my child and call me later to review the care. If my child has a lab test and has private insurance, I might get a bill from the laboratory. If my child has Medicaid or no insurance, I will not get any bill. The Life Health Center School Wellness Program may use telemedicine (video) to provide mental and medical health services. If video is used, there will be no recording of the video. This is the list of services that we offer. If you do NOT want your child to get any one of these services, please cross it off the list. If you are okay with all these services, please check this box: Physical Health Behavioral/Emotional Health Lab Tests Evaluation and treatment of minor illness or Evaluation for emotional Blood test injury problems Throat culture Flu vaccine Individual therapy Urine test Other vaccines that my child needs Group therapy Vision screening (including eye glasses) Family therapy General check-ups Screening for medical problems What is your child s health insurance? None Medicaid Private Insurance Carrier Policy Number Group Number Policy Holder Social Security # of Birth EMERGENCY CONTACT INFORMATION Name: Relationship to Child: Phone Number: Name: Relationship to Child: Phone Number:

4 Notice of Privacy Practices The Life Health School Wellness Center (LHSWC) operates with money from the state of Delaware and from insurance. The law requires that certain LHSWC staff provides specific patient information to DPH for certain reasons: To measure disease activity in Delaware and the United States To prevent or control disease or injury in Delaware and the United States Information that will be reported includes: sexually transmitted disease, laboratory tests about reportable diseases (some infections), deaths, adverse medication reactions, child abuse or neglect Information about services that your child receives will also be shared with your child s health insurance. You can get a copy of your child s records by: HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) The Life Health School Wellness Program must follow the HIPAA Privacy Rules. By law we are required to give you with a copy of this Notice of Privacy Practices. By signing below I understand that if I have any questions I may call the Wellness Center Coordinator at for more information before I sign this authorization. Name of Parent/Legal Guardian ACKNOWLEGEMENT OF HIPAA & GENERAL POLICIES I have received a copy of the following: HIPAA Notice of Privacy Practices Counseling Practice Policies and Processes Parent/Guardian Signature

5 RELEASE OF INFORMATION Please sign this form if you would like us to get and share medical information (for example, vaccine records and medicines) with your child s doctors. We believe this is very important so we can provide the best possible care. I, (Parent/Guardian), on behalf of (Child s name) give my permission for The Life Health Center staff to give my child s medical records to get my child s medical records from Please list all the doctors that you would like us to share information with: Doctor s Name Doctor s Address Doctor s Phone Number I understand that I do not have to sign this form for my child to receive care at the Life Health School Wellness Program. I understand that if I do not sign this form, it might be hard for the doctors to have all the information needed to provide the best possible care. This permission will only be good for 365 from the signed consent. I understand that I can cancel this permission at any time by writing a letter to The Life Health School Wellness Program at Eisenberg. I can send the letter by or by mail to the address below. I understand that the staff may share information in any way that is needed (paper, fax, , telephone). If I prefer a different way to share information, then I will write a letter to the Life Health School Wellness Program. I understand that the Life Health School Wellness Program cannot share any information about my child with anyone that I have not listed on this form.

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