West Wilkes Middle School

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Parents » MESH Counseling Services

MESH Counseling Services

Image of logo for Jodi Province Counseling.

1260 College Ave. Ste. 1

Wilkesboro, NC 28697

Phone: (336) 818-0733

 

 

 

2018-2019 School Year

 

Dear Parents of Middle School Students,

 

We would like to take the opportunity to provide information regarding mental health services provided through the MESH (Mobile Expanded School Health) unit as part of the Wilkes County Health Department.  This is a free service to all middle school students, however if your child is a Medicaid recipient, Jodi Province Counseling Services, PLLC will bill Medicaid only for these services.  If you desire  your child to be seen for counseling in the school setting, please complete the back page/consent form and return it to your student’s school.  However, if your child wishes not to receive services, we will not provide services but do make every effort to present our services in a helpful and supportive nature to the students referred. 

 

There is no need to complete this form if you do not want services. 

We will be providing mental health services to address the following issues:

 

Anger/aggressive behavior

Depression

Anxiety

Disruptive behavior in the classroom

Grief

Family

School performance (grades)

Substance Abuse

Other issues as they arise

 

We also provide services in our offices located in Wilkesboro, Elkin, Jefferson, and Statesville.  We are available to provide services outside of the school setting as necessary.    Should you feel that we could meet any needs of your students, please do not hesitate to reach out to us with any questions.

 

Respectfully,

     Jodi

Jodi Province

Licensed Professional Counselor Supervisor

Certified Trauma Therapist

 

www.jodiprovincecs.com

jodi.province@gmail.com 

 

DATE:__________________ (Office Use Only: Provider):______________________________________________

NAME:___________________________________________________________________________________________________             

            FIRST                                                     MIDDLE INITIAL                              LAST

ADDRESS:________________________________________________________________________________________________

                 City                                                              State                                                      Zip

DATE OF BIRTH________________AGE________RACE_________ HOME/CELL PHONE_________________________

LEGAL GUARDIAN/RELATIONSHIP_______________________________________________________

SCHOOL ATTENDING_________________________________________GRADE____________________

EMERGENCY CONTACT/TELEPHONE_____________________________________________________

PRIMARY PHYSICIAN/TELEPHONE________________________________________________________

CURRENT MEDICATIONS_________________________________________________________________

ALLERGIES_________________________________________________________________________________

NATURE OF CONCERN REQUIRING COUNSELING_____________________________________________________

INSURANCE INFORMATION:  Does your child have Medicaid?____________

If yes, please provide the Medicaid#:_______________________________________________________

 

I/We consent that ___________________________________________ (minor’s name) may be treated as a client through the MESH unit with Jodi Province Counseling Services, PLLC. Please be aware that the law may provide parents/guardians the right to examine treatment records. It is our policy to provide parents/guardians access to information about treatment. However we also ask parents/guardians to trust us and allow us to keep your confidences on specific information and we will provide them with general information about your treatment sessions. We ask for your cooperation to provide the timeliest treatment for your children. I am aware that my child will be giving the therapist consent to speak with the school as needed for continuity of care. I agree to the informed consent and client rights of Jodi Province Counseling Services, PLLC that is located at www.jodiprovincecs.com.

 

 

Signature of Guardian                        Date

________________________________________________________________________________________________