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NEW HAVEN PUBLIC SCHOOLS SCHOOL HEALTH CENTER PERMISSION FORM

NEW HAVEN PUBLIC SCHOOLS SCHOOL HEALTH CENTER PERMISSION FORM

New Haven Public Schools operates 17 school health centers (SHC) located in K-8 and high schools. All students enrolled in their school’s SHC are eligible to receive services. The SHC providers do not replace your child’s regular health/mental health providers. NHPS works with community health partners to staff the SHCs during the school day so that students and parents need not miss school or work unnecessarily, and the SHC staff consult with your regular providers when needed. Our community partners include: Yale-New Haven Hospital, Fair Haven Community Health Center, Cornell Scott Hill Health Center, New Haven Health Department, and Clifford Beers Guidance Clinic. All services are free to students (no cost/fees to families), though billable services may be submitted directly to your insurance companies. All students under age 18 must have a parent permission form completed/signed by a parent/guardian to receive services in a SHC.

SHCs are staffed by a team of licensed professionals that usually include a medical provider (nurse practitioner or physician assistant), a social worker and an office manager/clerk. The medical provider offers preventive medical services like immunizations and physical exams, acute care such as diagnosing, treatment and follow-up of illnesses and injuries, and management of chronic conditions like Asthma and Diabetes. The social worker provides assessment, individual/group/family counseling, student support groups, crisis intervention, and short/long term therapy as needed. All SHC providers work closely with the family, community providers, and with the school nurse and school staff to ensure that students get the care they need at school, or through community support services. To enroll your child/ren in the SHC, please complete and sign one permission form for each child at this school, and be sure all information on the front and back of this permission form is complete.

Primary Information

First
Last
Address *
Address
City
State/Province
Zip/Postal
Primary Home Address *
Primary Home Address
City
State/Province
Zip/Postal
Who lives with Student (check all that apply)

Emergency Contact

Preferred Language

Medicaid or Husky Insurance

Type of Insurance (check all that apply and complete information below on your child’s insurance coverage) *

Private / Commercial Insurance

Policy Holder’s Address *
Policy Holder’s Address
City
State/Province
Zip/Postal
Address *
Address
City
State/Province
Zip/Postal
Address *
Address
City
State/Province
Zip/Postal
Where do you usually get your child’s medical care? *
Address *
Address
City
State/Province
Zip/Postal

New Haven Public Schools - School Health Centers

 Clinton Avenue (475) 220-3318 

 Brennan-Rogers (475) 220-2216 

 Lincoln-Bassett (475) 220-8516 

 Davis Street (475) 220-7815 

 Truman (475) 220-2122

 Riverside Academy (475) 220-6704

Fair Haven (475) 220-2643

King-Robinson (475) 220-2791

Roberto Clemente (475) 220-761

Mauro-Sheridan (475) 220-2815

Troup (475) 220-307

John S. Martinez (475)220-2017

Hillhouse (475) 220-7555

Wilbur Cross (475) 220-7444

Career (475) 220-504

Hill Central (475) 220-6119

 Truman (475) 220-2122

Barnard (475) 220-358

School Health Center services Aavailable to students:

Ages 3-18:

School Physical Exams

Treatment of Asthma, Anemia, Acne and Other Health Problems

Nutrition and Weight Counseling

Referral for Specialty Care

Immunizations

Mental Health Individual and Group Counseling

Diagnosis and Treatment of Minor Illness/Injuries

Issue-oriented Support Groups

Substance Abuse Education/Counseling

Crisis Intervention

Ages 12-18:

HIV/AIDS/STD Education, Counseling and Testing

HIV/STD Prevention (including condom availability)

Pregnancy Testing

Reproductive Health

Contraceptive services available to female students

Does your child have a history of one of the following

I have read the materials supplied to me regarding the services of the School Health Center and I give permission to the above named student to use the services provided by the School Health Center for as long as she/he is enrolled in the New Haven Public Schools. I do not, want my child/ward to receive the following services from the School Health Center: *

As the parent/guardian of the student identified above, I understand that I may revoke the permission at any time for any reason and that I may add to or subtract from the services I do not want my child/ward to receive by informing the School Health Center staff in writing that I wish to withdraw or change my permission/instructions. I give the SHC staff permission to communicate with key school personnel if needed, to facilitate quality case management. Furthermore, I give permission to the School Health Centers to release information regarding treatment and/or services to the above insurance providers for the purpose of billing. I authorize payments to be made directly to the agency providing services or New Haven Public Schools. I also give permission to receive services through Telehealth, if available. I also acknowledge receipt of the SBHC Privacy Notice.