Cover Letter

Seattle-King County Department of Public Health
Alonzo L. Plough, Ph.D., MPH, Director

Dear Parents/Guardians:

Welcome to the 1996-1997 school year! We would like to share information with you about the Teen Health Centers in the Seattle Public Schools and encourage you to enroll your child in the Teen Health Centers, if you have not done so in the past.

The Teen Health Centers are located in eight high schools (Cleveland, Franklin, Garfield, Nathan Hale, Sealth, Rainier Beach, Roosevelt, West Seattle) and serve students from 8 high schools, 2 middle schools (Madison and Denny), and 3 alternative schools (Summit 6-12 grades, Nova, and Marshall). The Teen Healtl1 Centers provide comprehensive, high quality services to keep students physically and mentally healthy. Each Teen Health Center is staffed by a full-time Nurse Practitioner, a Mental Health Counselor, and a Receptionist/Patient Care Coordinator. All are trained to work especially with adolescents.

Various community health agencies operate the Teen Health Centers. The Seattle-King County Department of Public Health coordinates and oversees the Teen Health Centers.

Before providing services to a student, Teen Health Centers must have a signed consent from a parent or legal guardian, except in situations where federal and/or state laws allow teens to access treatment without parent/guardian consent (e.g., reproductive health care, drug/alcohol and mental health counseling). This policy was developed with the Seattle Public Schools to ensure that the Teen Health Centers follow federal and state laws.

Student consent is legally required for release of information about reproductive health care, drug/alcohol and mental health counseling. However, staff at the Teen Health Centers are committed to encouraging family communication about healtl1 issues. We encourage students to provide their consent for us to involve parents whenever possible.

In the next month or two, you will receive additional information from the Teen Health Center that serves the school your student attends. In the meantime, please feel free to call the Seattle-King County Department of Public Health at 296-4987 or 205-9177 if you have questions or would like more information.

We welcome your student — and you — to the Teen Health Centers and look forward to ensuring a safe and healthy school year.

Sincerely,

Tara Wolff, MPH
Manager, School Age Health
Seattle-King County Department of Public Health
Anne St. Germaine, Ph.D., RN
Coordinator, Comprehensive School Health
Seattie Public Schools


Teen Health Centers are a collaborative program of the Families and Education Levy, City of Seattle,
Seattle-King County Department of Public Health, Seattle Public Schools, and Community Agencies. 110 Prefontaine Place South, Suite 500 Seattle, Washington 98104-2614 (206) 296-46000 (V/TDD)

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Parental Consent Form

Seattle-King County Department of Public Health

I understand that, in accordance with Seattle School District policy, Teen Health Centers must have a signed consent from a parent or legal guardian before providing services to teens, except in situations where federal and/or state laws allow students to access such treatment without parent/guardian consent (e.g., reproductive health care, drug/alcohol and mental health counseling). I understand that if I choose not to enroll my child in the Teen Health Centers, he/she will continue to receive school nurse services. I hereby request and authorize that

Print Student’s first name, middle initial, and last/family name


Birth date


receive any and all health care services available from and deemed necessary by the staff of the Teen Health Center and its provider agencies listed above. These services may include, but are not limited to, such procedures as well teen care, evaluation and treatment of acute illnesses and injuries, immunizations, contraception, blood studies, photographs and X-rays. Consent is specifically given for care in the event the above named student presents him/herself for treatment in my absence. I understand the student’s consent is legally required for release of information about the following kinds of diagnoses and treatment: pregnancy, sexually transmitted diseases (including HIV/AIDS testing), and alcohol and drug or mental health counseling. I understand, however, that I will be informed if the Teen Health Center staff feels the student is a danger to him/herself or others.

Consent is also given for referral of care and if needed, emergency transportation, to other physicians, health care professionals, hospitals, clinics, or health care agencies as deemed necessary by the Teen Health Center and its staff. Consent is given to contact such persons or agencies for the purpose of providing or receiving information and records relative to the above listed student.

This authorization does not allow services to be rendered without the student’s consent, unless unable to consent.

The consent for services is authorized for the length of time the student is enrolled in a school with a Teen Health Center. I may choose to withdraw the consent at any time by writing to the Teen Health Center that serves the student.

Parent/Guardian Signature


Date


 

Name and Relationship of Legally Responsible Guardian (Please Print)


Parent/Guardian Address



 

Home Telephone


Work Telephone


 

Student Signature


Date


Return the completed form to the Teen Health Center
that serves the school your student attends.
 

Teen Health Centers
Parent/Guardian Consent for Health Services

I have read the attached Teen Health Center information and understand the services offered by the following Teen Health Centers:

Garfield/Nova Teen Health Center
Garfield High School
400 – 23rd Ave.
Seattle, WA 98122
phone 860-0488
Agencies: Odessa Brown Children’s Clinic (a satellite of Children’s Hospital & Medical Center); Carolyn Downs Family Medicine Clinic
West Seattle/Madison Teen Health Center,
West Seattle High School
4075 SW Stevens
Seattle, WA 98116
phone 935-8369
Agency: Medalia Health Care; Southwest Youth & Family Services; Pacific Medical Center.
Nathan Hale/Summit Teen Health Center
Nathan Hale High School
10750 – 30th Ave. NE
Seattle, WA 98125
phone 363-8291
Agencies: Division of Adolescent Medicine, University of Washington; School of Nursing, University of Washington; Center for Human Services
Cleveland Harborview Health Center
Cleveland High School
5511 – 15th Ave South
Seattle, WA 98108
phone 521 – 1260
Agency: Harborview Medical Center; Seattle Mental Health Institute; Asian Counseling & Referral Service
Rainier Beach Teen Health Center
Rainier Beach High School
8815 Seward Park Ave South
Seattle, WA 98118
phone 296-4639
Agencies: Columbia Health Center, Seattle-King County Dept of Public Health; Central Youth & Family Services
Roosevelt/Marshall Teen Health Center
Roosevelt High School
1410 NE 66th St.
Seattle, WA 98115
phone 527-8336
Agencies: Providence Medical Center and 45th Street Clinic
Sealth/Denny Teen Health Center
Sealth High School
2600 SW Thistle St.
Seattle, WA 98126
phone 938-1360
Agencies: Puget Sound Neighborhood Health Centers; Southwest Youth & Family Services
Franklin Teen Health Center
Franklin High School
3013 S. Mt. Baker Blvd.
Seattle, WA 98144
phone 326-2750
Agency: Group Health Cooperative; Central Youth & Family Services; International District Community Health Center

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Teen Health Center
Student Information Form
 

Please provide the following student information. This information will be used for understanding who the teen health center serves. The information will also help the teen health center better serve its clients. This information is confidential. We will not give out this information with the student’s name. Thank you for your cooperation!

Print Student Name


First name, Middle initial, Last/family name


Birth Date

 

Please circle the correct information:

1. Gender of the student

Male Female

2. Grade of the student

6th 7th 8th 9th 10th 11th 12th

3. Ethnicity of the student (check only one)

__Japanese
__Chinese (includes Taiwanese, Hong Kong, Chinese Vietnamese, etc)
__Filipino
__Southeast Asian (Vietnamese/Cambodian or Khmer/Laotian, Mien, Hmong, or Khmu, etc)
__Korean
__Pacific Islander (e.g., Hawaiian, Samoan, Fijian, Tahitian, Micronesian, etc)
__Other Asian (e.g, Thai, East Indian, Pakistani, etc)
__Multiethnic Asians/Pacific Islanders like Korean/Chinese or Samoan/Filipino
__African American/African descent (Black)
__Latino/Mexican/Puerto Rican/Central American/South American/Hispanic
__Native American Indian
__Alaska Native
__Caucasian/European-American excluding Hispanic
__Multiracial (self identify as Latino/African American, Samoan/Caucasian, etc)
__Other Group not Listed (e.g., Arab, Afghan, etc)

 

4. What is the primary language spoken at home?


Return the completed form to the Teen Health Center that serves the school your student attends.