The above-named patient (student or employee) has my consent to receive services offered by the Glenbrook School Health Center, located at Glenbrook South High  School and its contracted provider, Advocate Aurora Healthcare.  In providing my informed consent, I understand that:

1. I/the student will not be charged for any services provided by the Glenbrook School Health Care Center.  However, Medicaid reimbursement, where applicable, may be sought for such services.
2. The patient has the right to refuse any and all services.
3. Available services offered in the Glenbrook School Health Center will be similar to what community members can receive in a pharmacy-based, low-acuity immediate care center including, but not limited to:
   
   • Required school and sports physical examinations, required immunizations, and COVID-19 testing and vaccinations;
   • Diagnosis and treatment of acute illness and injury;
   • Diagnosis and management of chronic illness;
   • Health education and promotion;
   • Wellness promotion including smoking cessation, nutrition, weight management;
   • Laboratory tests including throat cultures, complete blood counts, mono spots, etc.;
   • Mental health counseling services;
   • Dental examination and treatment;
   • Referrals to other linkage agencies for services not provided at the Glenbrook School Health Center.
4. No reproductive healthcare services will be provided.
5. If a service is requested or needed by the patient outside of the regular school day or outside of the scope of services offered by the Glenbrook School Health Center, Advocate Aurora Health will offer a referral.
6. Services provided by the Glenbrook School Health Center may be on-site and/or through telehealth communications if appropriate.
7. Telehealth includes the practice of health care delivery, including mental health care delivery, evaluation, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, and/or data communications.  Telehealth may involve the communication of medical/mental health information, both orally and visually, to other healthcare professionals.
8. The services provided by the Glenbrook School Health Center are not intended as primary care services and are not a substitute for parental/eligible student monitoring of the student’s health or regular visits to a primary care physician.
9. Confidentiality of all medical records will be maintained by the Glenbrook Student Health Center and Advocate Aurora Healthcare as required under applicable federal and State laws and regulations, including but not limited to the Health Insurance Portability and Accountability Act (HIPAA), Consent by Minors to Health Care Services Act, Illinois Mental Health and Developmental Disability Code, the Illinois Mental Health and Developmental Disability Confidentiality Act, and 77 Ill. Admin. Code Part 641.
10. The results of school and sports physical examinations and immunizations may be shared reciprocally with Glenbrook High School District 225.
11. Therapists have mandated reporters of child and elderly abuse and neglect under state law, meaning we are required to report any disclosed or suspected incidents of child or elderly abuse or neglect to the Illinois Department of Children and Family Services hotline in accordance with the Abuse and Neglect Child Reporting Act.
12. The Glenbrook School Health Center staff is required to report to the IDHS FOID Mental Health Reporting System for persons that we determine to be a clear and present danger to themselves or others, and if we determine a person to be developmentally or intellectually disabled.
13. Should a patient present a risk of harm to themselves or another person, it may be necessary to disclose confidential information in an attempt to protect the patient or alert the person who is in danger of harm.  If suicide is a risk, we may, as permitted by law, seek to hospitalize or contact a family member or others to help with protection.
14. To the extent permitted by law our therapists share with parents any general progress reports for children and adolescents, and will disclose to parents if the child/adolescent is in an emergency or is at risk for or is committing potentially dangerous or harmful behaviors.
15. To the extent permitted by law our therapists share with parents any general progress reports for children and adolescents, and will disclose to parents in the child/adolescent is in an emergency or is at risk for or is committing potentially dangerous or harmful behaviors.
16. In consideration for the student’s participation in the Glenbrook School Health Center and as evidenced by my signature below, I hereby release and hold harmless Glenbrook High School District 225 and its Board of Education and administration, employees, agents, and representatives from any liability which may accrue to me and/or the student for any and all losses, injuries, or damages to me and/or the student, both known and unknown, foreseen and unforeseen, arising out of or in connection with the student’s participation in the Glenbrook School Health Center.
17. The patient will not receive services at the Glenbrook School Health Center unless a signed Consent form is on file.
18. I understand that a parent, legal guardian, or student who is permitted under Illinois law to consent on his or her own behalf has a right to refuse any health care services. 
19. I further understand that under Illinois law, a minor over age 12 has the same capacity as an adult to consent to certain health services and no parental permission is required for such services.
20. I consent to the release of relevant health information and medical records in connection with treatments at the Glenbrook School Health Center and its collaborating partners to facilitate my child’s health needs.  I further authorize the Glenbrook School Health Center to release information regarding my child’s treatment to third-party payors or others for billing, program management, and evaluation in accordance with federal and state laws and regulations regarding confidentiality.
21. I understand that if my child is 12 or older they can receive mental health and substance abuse services at the Glenbrook School Health Center without my consent.  Per 405 ILCS 5/3-5A-105(a), they may receive up to eight 90-minute sessions for mental health services.  By law, a child under age 12 will not be allowed to receive mental health/substance abuse services without parental consent.
22. The patient or their parent/legal guardian may revoke this consent or stop or refuse services at any time.  Revocation of consent will be provided in writing to the Glenbrook School Health Center director or health care provider.

By my signature below, I also authorize the Glenbrook School Health Center and/or Advocate Aurora Health Care to release information to Medicaid, where applicable, for purposes of billing, in accordance with all federal and State laws and regulations.