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  • Youth and Family Forms

    Select the form(s) below:
  • What school does the student attend?*
  • Are you currently enrolled in the health center?

  • You must be enrolled in the health center to complete the School-Based Health Center Mental Health Services Referral. Please select another form option.

  • School-Based Health Center Enrollment

  • Our School-Based Health Center provides medical and behavioral health services within a safe, comfortable school environment, so that high-quality care is within easy access to students regardless of current situation. Services in this program are provided at no direct cost to the student or family. Costs are covered by your health insurance, the New York State Health Department, federal grants and Rochester Regional Health grants.

    The School-Based Health Center is staffed by caring and dedicated Licensed Social Workers/ Mental Health Therapists, Psychiatrists, Nurse Practitioners, Pediatricians and Medical Assistants, Outreach Workers and Office Assistants. These professionals are committed to providing care and support for students in need, and to working closely with the family’s regular doctor in the community to ensure that each student receives consistent care.

    Learn more about our School-Based Health Centers

  • Student Information

  • Student Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Is it okay to text this number?*
  • Is it ok for the Health Center to email student?*
  • Student's preferred form of communication*
  • Student Gender*
  • Student Ethnicity*
  • Is the student 18+ or emancipated?*
    •  

    • Parent/Guardian Information

    • Parent/Guardian's Date of Birth*
       - -
    • Format: (000) 000-0000.
    • Parent/Guardian/s preferred method of contact*
    • Is it ok for the Health Center to email parent/guardian?*
    •  
    • Format: (000) 000-0000.
    •  

    • Student Medical History

    • Does the student have allergies?
    • Does the student currently have any medications?
    • Does the students have any health conditions/problems?
    • Are there any other concerns regarding student's health?
    • Are you interested in mental health services?
    • Are you interested in family peer advocate supports?
    •  

    • Student Health Insurance Information

    • Does your child have medical coverage?*
    • If you do not have insurance may someone contact you to assist with insurance enrollment? A SBHC team member will work with you to obtain insurance for your family, for free!*

    • CONSENT TO TREATMENT

      I consent for my child to receive health care services provided by Rochester Regional Health as part of the School-Based Health Center program approved by the New York State Department of Health. I understand that confidentiality between the student and the health provider will be ensured in specific service areas in accordance with the law, and that students will be encouraged to involve their parents or guardians in counseling and medical care decisions. I further authorize the exchange of medical information with other medical providers who have examined the child named on this form and our insurance provider. School-Based Health Center services may include, but are not limited to:

      1. Comprehensive physical examination (complete medical examination) including those for school, sports, working papers and new entrants.
      2. Medically prescribed laboratory tests such as for anemia, sickle cell, and diabetes.
      3. Medical care and treatment, including diagnosis of acute and chronic illness and disease, and dispensing and prescribing of medications.
      4. Mental health services including evaluation, diagnosis, counseling, and referrals.
      5. Reproductive health care services, including contraception, (birth control pills, Depo (the shot) etc, testing for pregnancy, STD screening and treatment, HIV testing, PAP smears, and referrals for abnormal results, as age appropriate.
      6. Nutrition and weight counseling.
      7. Health education and counseling for the prevention of risk-taking behaviors such as: drug, alcohol and smoking abuse, as well as education on abstinence and prevention of pregnancy, sexually transmitted infections, and HIV, as age appropriate.
      8. Referrals for service not provided at the school based health center.
      9. Refractive vision screening for prescriptive eyewear.
      10. Access to care is available 24 hours a day, seven days a week. Call 585-922-SBHC.

      I have read and understand the services listed above and my signature below documents consent for my child to receive services provided by the School-Based Health Center. NOTE: By law, parental consent is not required for the conduct of mandated screenings, the application of first aid treatment, pre-natal care, services related to sexual behavior and pregnancy prevention, and the provision of services where the health of the student appears to be endangered. Parental consent is not required for students who are 18 years or older or for students who are parents or otherwise legally able to sign on their own behalf. You may view Rochester Regional Health’s Notice of Privacy Practices and Patient Bill of Rights at 

      https://www.rochesterregional.org/patients-visitors/patient-forms

    • I have read and understand the services listed above and my signature below documents consent for my child to receive services provided by the School-Based Health Center. NOTE: By law, parental consent is not required for the conduct of mandated screenings, the application of first aid treatment, pre-natal care, services related to sexual behavior and pregnancy prevention, and the provision of services where the health of the student appears to be endangered. Parental consent is not required for students who are 18 years or older or for students who are parents or otherwise legally able to sign on their own behalf. You may view Rochester Regional Health’s Notice of Privacy Practices and Patient Bill of Rights at https://www.rochesterregional.org/patients-visitors/patient-forms*
    • Today's Date
       - -

    • CONSENT TO TELEMEDICINE AND TYTO CARE SERVICES

      By completing this form, you (student or parent/guardian) are providing consent for the student(s) to receive health care services via a telemedicine visit with RRH. This permission will remain in effect until the student is no longer registered at the school or until it is withdrawn in writing to RRH or RCSD’s General Counsel.

      Confidentiality: The laws that protect privacy and the confidentiality of medical information also apply to telemedicine. The telemedicine provider and their agents will respect patient privacy and confidentiality during this electronic exchange of information. The information captured will be maintained, stored and safeguarded in the same fashion as any face-to-face or other form of interaction between a patient and health care provider. By signing below, you give RRH permission to use and disclose health information for treatment, payment and RRH health care operations. RRH will not record any visit without consent. Any recorded images needed for evaluation, diagnosis or treatment purposes created during a telemedicine visit will not be displayed, broadcast, or otherwise shown outside the health care setting without additional authorization. While RRH encourages every patient to involve parent(s)/legal guardian(s) in all treatment decisions, certain information must remain confidential unless the student consents to disclosure of such information to parent(s)/guardian(s).

      Read our full telemedicine patient rights and responsibilities at https://www.rochesterregional.org/patients-visitors/patient-forms

      Telemedicine Services: Telemedicine visits with RRH may include, but are not limited to, the following services:

      1. Respiratory Issues: (allergy/asthma, cough, congestion, sore throat, COVID symptoms)
      2. Infections: (ear/nose/throat, skin, pink eye)
      3. Mild traumas: (cuts/abrasions, aches/pains, sprains/strains)
      4. Topical / Dermatological Issues: (rash/poison ivy, burns/abrasions, skin infection, bites)
      5. Routine Follow-up for Chronic Conditions: (ADHD, anxiety, asthma, diabetes mellitus, obesity)
    • By signing below, I am agreeing that I have read and fully understood the contents of this document and all of my questions have been answered. I consent to the student listed below receiving telemedicine services as described in this document:*
    • Today's Date
       - -

    • I give my consent to the school nurse to administer the following medications as ordered by the SBHC Nurse Practitioner and/or physician after a telemedical appointment. Medication orders expire at the end of the school day on the day of SBHC clinic appointment.

      • Acetaminophen (Tylenol) 15mg/kg Ibuprofen (Motrin/Advil) 10mg/kg
      • Benadryl antihistamine (for generalized allergic reaction) 5mg/kg /day (divided into 3 or 4 doses) Loratadine 10mg
      • Triple antibiotic ointment Saline (salt water gargle) mouth rinse Benadryl or cortisone cream (topical itching/rash)
      • Tums antacid
      • Cough Drops
    • Student's Date of Birth*
       - -
    • Today's Date*
       - -
    • I'd like to be notified when medication is administered*

  • School-Based Health Center Mental Health Services Referral

  • Date of Referral*
     - -
  • Student's Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Date Parent/Guardian contacted and agreed to referral*
     - -
  • Does the student currently receive in-school counseling or community mental health services?*
  • Does the student have a 504/IEP?*
  • Presenting Problem/Reason for Referral*

  • If Yes to Suicidal Thoughts/past attempts/Self-Harming Behaviors, please ask:

  • In the past two weeks, have you had thoughts of killing yourself?*
  • In the past six months, have you attempted to kill yourself?*

  • Family Peer Advocate Referral

  • Date of Referral
     - -
  • Student's Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Does the student currently receive in-school counseling or community mental health services?*
  • Does the student have an IEP/504?*
  • Presenting Problem/Reason for Referral*

  • Community Youth Behavioral Health School Referral Form

  • Student Date of Birth*
     - -
  • Are parents in support of preferred name/pronoun?*
  • Legal Guardian?*
  • Format: (000) 000-0000.
  • Special education or other In-School Services or 504 plan?*
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  • Presenting Problem/Reason for Referral*
  • In the past two weeks, have you had thoughts of killing yourself?*
  • In the past six months, have you attempted to kill yourself?*

  • Submit Form

    Please submit your forms using the button below. Thank you.
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