1260 College Ave. Ste. 1
Wilkesboro, NC 28697
Phone: (336) 818-0733
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:
Disruptive behavior in the classroom
School performance (grades)
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.
Licensed Professional Counselor Supervisor
Certified Trauma Therapist
DATE:__________________ (Office Use Only: Provider):______________________________________________
FIRST MIDDLE INITIAL LAST
City State Zip
DATE OF BIRTH________________AGE________RACE_________ HOME/CELL PHONE_________________________
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