Private Counseling Services
Ammonoosuc Community Health Services, Inc.
Dear Parent/Guardians,
Late last summer, Superintendent Laurie Melanson approached Ammonoosuc Community Health Services (ACHS) with the idea of delivering much-needed behavioral health services directly to SAU 23 schools. The thought was that by removing barriers in transportation and cost we could make it easier for students to get the services they deserve. With this collaborate effort, ACHS is pleased to now offer counseling services at your child’s school.
Could your child benefit from speaking to a behavioral health specialist during school? ACHS can help!
ACHS is a Federally Qualified Community Health Center providing integrated primary care to over 10,000 residents at our six area sites. At your school, our team of licensed behavioral health specialists will provide guidance and emotional support to students, as well as conduct assessments of individuals who may need additional treatment either by ACHS or other community resources. We’ll use a wide variety of counseling services, including educational, group, family and individual counseling to deliver the best quality care.
As a community health center providing integrated primary care services, ACHS can bill your public and or private insurance carrier for counseling services. We also offer a sliding fee payment scale for those who qualify. If you think your child could benefit from at-school behavioral health services, please complete the enrollment packet and provide parental or legal guardian consent.
The ACHS team is looking forward to working with you and your child as well as the staff of SAU 23. We welcome your feedback and would be glad to answer any questions you have. You can reach our team is through our support person Meg Trudell at 444-8296.
Sincerely,
Stephen Noyes, LICSW
Director of Integrated Behavioral Health
Ammonoosuc Community Health Services, Inc.
As a parent and or legal guardian you should know that due to federal privacy laws, substance abuse services for individuals 13 years of age and older maybe delivered without parental consent or knowledge. In most instances we work with the student to encourage them to involve their parents and other loved ones in their care. Under these laws however, an individual cannot be forced to involve parents or release protected information. There are also instances when a child reports neglect, physical and or sexual abuse which requires us to report this to the division of children youth and family services. This, like the laws to protect substance abuse information, can be done without the knowledge and or consent of the parent or legal guardian.
25 Mt. Eustis Rd. 79 Swiftwater Rd. 14 Kings Square 1095 Profile Rd., Suite B Rte. 25, Main St.Littleton, NH 03561 Woodsville, NH 03785 Whitefield, NH 03598 Francoina, NH 03580 Warren, NH 03279
(603) 444-2464 (603) 747-3740 (603) 837-2333 (603) 823-7078 (603) 764-5704
F (603) 444-5209 F (603) 747-0416 F (603) 837-9790 F (603) 823-5450 F (603) 762-5705
www.ammonoosuc.com [email protected]
ACHS – Littleton
25 Mount Eustis Road Littleton, NH 03561
6034442464 Fax: 6034445209
Website: www.ammonoosuc.org
Today’s Date: _____/_____/_____
Parental Consent for Treatment & Care of Minors
Patient Name: _________________________________ Date of Birth: _____/_____/_____
I,_______________________________________ , being the parent and/or legal guardian of the minor age child listed above, hereby give consent for medically necessary treatment and care, including emergency treatment, by the health care providers affiliated with Ammonoosuc Community Health Service, Inc. In the event I am not available at a time this minor requires medical care, I give the parties listed below the authority to seek and authorize care.
This consent will remain in effect until I sign a written revocation.
________________________________________
Signature of Parent/Legal Guardian Date
________________________________________
Printed Name Date
Alternate Parties Authorized to Seek Medical Care for Minor Child
- __________________________________
Printed Name Relationship
Contact Number ___________________________ Initial of Legal Guardian
- __________________________________
Printed Name Relationship
Contact Number ___________________________ Initial of Legal Guardian
- __________________________________
Printed Name Relationship
Contact Number ___________________________ Initial of Legal Guardian
Patient Registration Form (Please Print)
Primary Care Provider: _____________________________________________
| Name: Last | First: | Middle: | Suffix: | |||||||||||||||||||
| Alias (Former Name) | Preferred Name/Nickname: | |||||||||||||||||||||
| Title: ❒ Mr. ❒ Miss ❒ Ms. ❒ Mrs. ❒ Dr. | Gender: ❒ Male ❒ Female | |||||||||||||||||||||
| Birth Date: | Social Security #: | |||||||||||||||||||||
| Email: | Photo ID provided: ❒ | |||||||||||||||||||||
| Physical Address: | Mailing Address: | |||||||||||||||||||||
| City: | State: | Zip: | City: | State: | Zip: | |||||||||||||||||
| Phone: Home | Cell | Work | ||||||||||||||||||||
| May we contact you at home? ❒ Yes ❒ No | May we contact you at work? ❒ Yes ❒ No | |||||||||||||||||||||
| If the answer is no to the above, with whom may we leave a message? | ||||||||||||||||||||||
| Phone: Home | Cell | Work | ||||||||||||||||||||
| May we say “Ammonoosuc Community Health Services, Inc.” is calling? ❒ Yes ❒ No | ||||||||||||||||||||||
| Preferred method of contact: ❒ Letter ❒ Home Phone ❒ Cell Phone ❒ Work Phone ❒ Email ❒ Portal | ||||||||||||||||||||||
| Marital Status: | ❒ Single | ❒ Married | ❒ Divorced | |||||||||||||||||||
| ❒ Widowed | ❒ Separated | ❒ Other ________________________________ | ||||||||||||||||||||
| Employment Status: | ❒ Employed | ❒ Unemployed | ❒ Disabled | ❒ Retired | ||||||||||||||||||
| Preferred Pharmacy: | Location of Pharmacy: | |||||||||||||||||||||
| Emergency Contact: | Relation: | |||||||||||||||||||||
| Mailing Address: | Physical Address: | |||||||||||||||||||||
| City: | State: | Zip: | City: | State: | Zip: | |||||||||||||||||
| Phone: Home | Cell | Work | ||||||||||||||||||||
| Does contact know you are an ACHS patient? ❒ Yes ❒ No | ||||||||||||||||||||||
| Party responsible for payment: | ❒ Patient | ❒ Spouse | ❒ Parent | ❒ Other ___________________ | ||||||||||||||||||
| Please complete the remainder of this section ONLY if another party is responsible for payment: | ||||||||||||||||||||||
| Name: | Date of Birth: | |||||||||||||||||||||
| Address: | ||||||||||||||||||||||
| City: | State: | Zip: | ||||||||||||||||||||
| Phone: Home | Cell | Work | ||||||||||||||||||||
| Medical Treatment/Payment Agreement for Ammonoosuc Community Health Services: | ||||||||||||||||||||||
| ❒ Self-Pay/Uninsured | ❒ Sliding Fee Scale Application completed | |||||||||||||||||||||
| Primary Medical Insurance: | ❒ Copy of card given | |||||||||||||||||||||
| Policy Holder:
Name and Date of Birth: |
❒ Patient | ❒ Spouse | ❒ Parent | ❒ Other _____________________ | ||||||||||||||||||
| Secondary Medical Insurance: | ❒ Copy of card given | |||||||||||||||||||||
| Policy Holder:
Name and Date of Birth: |
❒ Patient | ❒ Spouse | ❒ Parent | ❒ Other _____________________ | ||||||||||||||||||
| Dental Treatment/Payment Agreement for Ammonoosuc Community Health Services: | |||||||||
| ❒ Self-Pay/Uninsured | ❒ Sliding Fee Scale Application completed | ||||||||
| Primary Dental Insurance: | ❒ Copy of card given | ||||||||
| Policy Holder:
Name and Date of Birth: |
❒ Patient | ❒ Spouse | ❒ Parent | ❒ Other ___________________ | |||||
| Secondary Dental Insurance: | ❒ Copy of card given | ||||||||
| Policy Holder:
Name and Date of Birth: |
❒ Patient | ❒ Spouse | ❒ Parent | ❒ Other ___________________ | |||||
| As a Federally Qualified Health Center, we are REQUIRED by Federal Law to collect the following information for statistical purposes only. This is reported annually on a total patient basis. Individual patient information is not reported or disclosed. Thank you for your cooperation! | |||||||||
| Primary Language: ❒ English ❒ Mandarin ❒ Spanish ❒ French ❒ Other __________________ | |||||||||
| Translation needed: ❒ Yes ❒ No | |||||||||
| Veteran Status: ❒ Veteran ❒ Non-Veteran | |||||||||
| Household | |||||||||
| Income: Total Gross Household Income: $ per ❒ week ❒ month ❒ year ❒ Decline to provide | |||||||||
| Size: Number of people in household this supports: | |||||||||
| Race: (Select up to 2) ❒ White ❒ Asian ❒ Black or African American ❒ American Indian or Alaska Native
❒ Native Hawaiian ❒ Pacific Islander ❒ Other ______________________ ❒ Decline to provide |
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| Ethnicity: ❒ Hispanic ❒ Non-Hispanic ❒ Decline to provide | |||||||||
| Sexual ❒ Straight (not lesbian or gay) ❒ Lesbian or gay ❒ Bisexual
Orientation: ❒ Something else ❒ Do not know ❒ Choose not to disclose |
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| Gender ❒ Male ❒ Transgender Male/ Female-to-Male ❒ Choose not to disclose
Identity: ❒ Female ❒ Transgender Female/ Male-to-Female ❒ Other |
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| Other: ❒ Homeless ❒ Migrant / Seasonal Worker ❒ Decline to provide | |||||||||
| How did you hear about our services? | |||||||||
| ❒ Outreach | ❒ Private MD | ❒ Phone Book | ❒ Media/Internet | ||||||
| ❒ Medicaid Office | ❒ Nurse/Counselor | ❒ Other Patient | ❒ Health Educator | ||||||
| ❒ Hospital/Health Agency | ❒ HMO | ❒ Family/Friend | ❒ Other Family Planning Clinic | ||||||
| Acknowledgements: | |||||||||
| Initial _________ | I certify that the information I have given is complete and accurate to the best of my knowledge. I understand that failure to provide accurate information may result in termination of services at ACHS and reporting of the failure to the federal government. | ||||||||
| Initial _________ | I request ACHS to provide me and/or my family with medical/dental care and request that ACHS bill my insurance company directly. I authorize release of any medical or other information necessary to process my claims. I also authorize payment of medical benefits to ACHS | ||||||||
| Initial _________ | I understand that I am responsible for any deductibles, co-payments, non-covered service, or Sliding Fee Scale. I understand that my failing to do so may result in my being submitted to collections, reported to the credit bureau, and / or terminated from services at ACHS | ||||||||
| Initial _________ | I acknowledge that I have received from ACHS the 1) Patient’s Bill of Rights/Contract of Care.
2) HIPAA Notice of Privacy Practices 3) PCMH Brochure |
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| Patient Signature: Date: / / | |||||||||
| ACHS Use Only:
Photo ID Verified by: ______________________________________________ Date: / / |
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ACHS 03/29/2017
