GMG Community School District Consent for School-Based Therapy 2020-2021

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Your child has been referred by his/her counselor to receive school-based therapy services during the 2020-2021 school year.  By signing below you are consenting to services and agreeing to the following terms:

  • Students will be taken out of class time to be seen by the Center Associates therapist. The amount of time will vary from 20 to 50 minutes per session depending on individual need.
  • A parent/guardian needs to be present for all Initial Assessments and Annual Reassessments as they come due. If a parent/guardian is unable to attend then the student will not be seen for school-based therapy. 
  • Parent/guardian involvement beyond the Initial Assessment will be determined by the Center Associates therapist. If it is decided that a parent/guardian is not effectively engaged in the student’s treatment, then he/she may be discharged from continued school-based therapy.
  • This referral is not a guarantee of ongoing therapy throughout the school year. There may be instances in which the Center Associates therapist determines the student is not appropriate for school-based therapy.  This information will be communicated with parents/guardians.
  • If applicable, the student’s insurance will be billed for all therapy appointments. The Marshalltown Community School District will be responsible for paying any copayments accrued for school-based therapy services only.
  • Any additional appointments (both therapy and medication management) occurring throughout the school year at the Center Associates office will be subject to Center Associates terms and conditions.
  • Given the additional dynamics related to COVID-19, particularly in grades 5-12, appointments may occur via teletherapy from the Center Associates clinician offsite to the student at school. All appropriate measures will be taken to ensure safety and security of PHI (personal health information).  The following risks associated with telehealth may occur: disruption of transmission by technology failures, interruption by unauthorized persons (i.e. school staff or students), and limited ability to respond to emergencies.  Center Associates and school staff will work diligently to minimize potential risks.  There will be no recording of any of the telehealth sessions by either party. All information disclosed within sessions and written records pertaining to those sessions are confidential and may not be disclosed to anyone without written authorization, except where the disclosure is permitted and/or required by law.

Any questions regarding school-based therapy services can be directed to your child’s school counselor, the Center Associates therapist assigned to your child’s school, or:

Kim Hagen, LISW

Clinical Director

Center Associates

khagen@centerassoc.com

641-752-1585

I have read the information provided above and I understand the information contained in this form.
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