Telehealth Authorization Form for Mental Health Services at Wayzata High School

Telehealth Authorization Form for Mental Health Services at Wayzata High School

The purpose of this form is to provide authorization for the below named student to receive mental health services via telehealth at Wayzata High School during school hours.
This information will be used by Wayzata High School to facilitate access to space and resources. This consent is valid for the current school year. I understand that I may revoke this consent at any time by providing written notice to the school, except to the extent that action has already been taken. Wayzata High School will maintain the confidentiality of the health information received and only use it for the intended purpose.
Student Name*

First NameLast Name
9101112
Student's Date of Birth*

MonthDayYear
Date
Student's Wayzata High School Social Worker
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Email Address*
example@example.com
Mental Health Provider Name*

PrefixFirst NameLast Name
Mental Health Provider Credentials*
Provider’s Organization, Practice, or Agency*
Provider's Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Provider's Email Address
example@example.com
Consent for Release of Information

I, the undersigned, hereby authorize my child's licensed mental health provider (or my licensed mental health provider if I am 16 years of age or older) to release information from my health record that is requested by the school to confirm that I am currently receiving mental health care from the provider. This consent is valid for the school year in which it is submitted.

I acknowledge and agree to the following:
1. Authorization Scope: This authorization allows the release of information from my health record solely to confirm that I am currently receiving mental health care from the named provider.
2. Validity Period: This consent is valid for the current school year.
3. Revocation: I understand that I may revoke this consent at any time by providing written notice to the school, except to the extent that action has already been taken in reliance on this consent.
4. Purpose of Release: The information will be used by the school to facilitate access to space and resources for mental health telehealth sessions during school hours.
5. Privacy and Confidentiality: The school will maintain the confidentiality of the health information received and will use it only for the intended purpose.
6. Supervision: I understand that Wayzata High School will not supervise my student during their telehealth appointment.
Parent/Guardian (if the student is under 16) or Student (if 16 or older) Signature*

Clear
Once this authorization form has been signed and submitted, please contact the student’s floor office to check for available space. While we cannot guarantee availability, if space is open, we will confirm with you and provide the student with a pass that includes the time and location of their telehealth appointment.

Students should plan to use either their school-issued iPad or a personal device, and should also have a backup plan in place in case of technical difficulties (such as switching to a phone call or rescheduling the session).
Should be Empty: