SBHC Registration

School-Based Health Center

Registration and Consent Form
Please fully complete and sign this form so we can provide high-quality healthcare services to every patient. This consent will remain active for the duration of the student’s enrollment at the school served by the SBHC unless expressly revoked in writing.

To provide the best care possible, we also ask for demographics and family health history. You have the right to refuse to answer these questions. Your answers will not be shared or used for any purpose other than gathering general demographic information to best serve our patients and community.
What school do you attend? At this time, services are only available to students who attend schools in the dropdown menu.
Are you a student requesting Confidential Mental Health or Sexual/Reproductive Health services?

YesNo
Student's Contact Information
Student's Legal Name*

First NameMiddle NameLast Name
Student's Date of Birth*

MonthDayYear
Student's Cell Number:
Student's E-mail*
example@example.com
Student's Appointment Notification Preference*

TextPhone Call
Student ID Number
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

School-Based Health Center

Registration and Consent Form
Parent/Guardian Information

Required if student is under 18 years old
Parent or Guardian Legal Name*

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Relationship to Student*
Parent/Guardian Notification Preference*

TextPhone Call
Cell Number:*
E-mail Address*
example@example.com
Add additional Parent or Guardian?*

YesNo
Parent or Guardian Legal Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Relationship to Student
Parent/Guardian Notification Preference

TextPhone Call
Secondary Cell Number:
E-mail Address
example@example.com
Is mailing address same as student's?

YesNo
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

School-Based Health Center

Registration and Consent Form
Student Demographics

To provide the best care possible, we also ask for demographics and family health history. You have the right to refuse to answer these questions. Your answers will not be shared or used for any purpose other than gathering general demographic information to best serve our patients and community.
Gender Identity
Sexual Orientation
Preferred Pronouns
Race
Choose all that apply
Ethnicity
Preferred Written Language*
Language Spoken at Home*
Does student need an interpreter?*

YesNo
Does parent need an interpreter?*

YesNo

School-Based Health Center

Registration and Consent Form
Insurance Information

The SBHC program is provided at no cost to you, but we will bill your insurance if you have any to support the cost of program operations. If your insurance does not cover the entire cost, you will not be billed.
Do you have health insurance?*

YesNo
Medical Insurance Information
Insurance Company
Subscriber Name

First NameLast Name
Subscriber Date of Birth

MonthDayYear
Date
Group Plan Number
Member ID Number
Policy Effective Date

MonthDayYear
Date
Do you have dental insurance?*

YesNo
Dental Insurance Information
Dental Insurance Company
Subscriber Name

First NameLast Name
Subscriber Date of Birth

MonthDayYear
Date
Group Plan Number
Member ID Number
Policy Effective Date

MonthDayYear
Date
Would you like a CHC Patient Service Specialist to contact you to see if your family qualifies for insurance?

YesNo

School-Based Health Center

Registration and Consent Form
Release and Consent Signature

I certify that the registration information that I have reported to Community Health Center of Snohomish County (CHC) is currently correct. I grant permission to CHC staff to employ such established treatments and therapies deemed professionally and medically necessary or advisable in the diagnosis or treatment of health problem(s). I understand that medical care may be given by a Physician, Physician Assistant, Nurse Practitioner, or other licensed staff. I understand that dental care may be given by a Dentist, Dental Hygienist, or other Dental providers in accordance with the Washington State Dental Practice Act. This release authorizes CHC to release to my insurance company, CMS, or DSHS any information needed to determine the benefits payable for related services. I hereby authorize any insurance carrier with whom I have a policy to pay directly any benefits of any policy of insurance to those health care providers who have rendered services to me.

Patients over 18 and those 13 and over seeking confidential mental health and/or reproductive health services should sign for themselves, Parent/Guardians should sign if patient is under 18.
Annual Income
Total Number in Household
Housing Status
At any point in the past two years, has seasonal or migrant farm work been you or your family’s primary source of income?

YesNo
Are you a Veteran?

YesNo

School-Based Health Center

Registration and Consent Form
Privacy Notice

Click here to view CHC's Notice of Privacy Practices

I hereby acknowledge I have received CHC’s Notice of Privacy Practices. I understand CHC of Snohomish County may contact me about appointment reminders, test results, treatment options, or other health related benefits and services via phone call, text message, email, or voicemail.

Patients over 18 and those 13 and over seeking confidential mental health and/or reproductive health services should sign for themselves, Parent/Guardians should sign if patient is under 18.
Initials Below:*

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School-Based Health Center

Registration and Consent Form
Release and Consent Signature

I certify that the registration information that I have reported to Community Health Center of Snohomish County (CHC) is currently correct. I grant permission to CHC staff to employ such established treatments and therapies deemed professionally and medically necessary or advisable in the diagnosis or treatment of health problem(s). I understand that medical care may be given by a Physician, Physician Assistant, Nurse Practitioner, or other licensed staff. I understand that dental care may be given by a Dentist, Dental Hygienist, or other Dental providers in accordance with the Washington State Dental Practice Act. This release authorizes CHC to release to my insurance company, CMS, or DSHS any information needed to determine the benefits payable for related services. I hereby authorize any insurance carrier with whom I have a policy to pay directly any benefits of any policy of insurance to those health care providers who have rendered services to me.

Patients over 18 and those 13 and over seeking confidential mental health and/or reproductive health services should sign for themselves, Parent/Guardians should sign if patient is under 18.
Full Legal Name*

First NameMiddle NameLast Name
Relationship to Student
Date*

MonthDayYear
Date
Signature*

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School-Based Health Center

Registration and Consent Form
Please fully complete and sign this form so we can provide high-quality healthcare services to every patient. This consent will remain active for the duration of the student’s enrollment at the school served by the SBHC unless expressly revoked in writing.

To provide the best care possible, we also ask for demographics and family health history. You have the right to refuse to answer these questions. Your answers will not be shared or used for any purpose other than gathering general demographic information to best serve our patients and community.
Consent for Care

Important Information About Minor Consent

The School-Based Health Center (SBHC) encourages students to involve their parents or guardians in healthcare decisions whenever possible and when applicable, the SBHC will assist the student in discussions with parents/guardians.

Under Washington State law, youth may independently access reproductive health care at any age without parental/guardian consent. Youth (age 13 and older) may independently receive drug and alcohol services and mental health treatment without parent/guardian consent. Consent from the student is required to release information regarding their reproductive health, mental health (over 13), and/or substance use (over 13).

For more information about minor consent visit: www.washingtonlawhelp.org and search “minor consent.”

{studentsLegal}, DOB {studentsDate}

I consent and authorize Community Health Center of Snohomish County (CHC) through its School-Based Health Center program to provide medical and dental services to my child. These services may include, but are not limited to: routine medical exams, sports physicals, well-child or teen care, evaluation and treatment of acute illness or injury, immunizations, laboratory testing, x-rays, salivary testing, dental and fluoride treatments. CHC encourages family involvement in the care we provide, however if I am unable to be present, authorization is given for my child to receive services in my absence. This care may be in-person, remotely via phone or telehealth, or both. Consent is also given for referral of care or if necessary emergency transportation to other health care professionals, hospitals, clinics, or healthcare agencies as deemed necessary by CHC staff. This consent does not allow services to be rendered without the student’s consent unless the student is unable to consent.

Consent is given to share necessary information with the health care providers at the SBHC, including exchange of information with the School Nurse and other co-located medical professionals for the purpose of providing the best care for the above named student.

With this consent, services can also be received at any CHC clinic. To see a list of clinic locations, please visit our website at www.CHCsno.org. To schedule an appointment, call CHC at 425-789-3789.

This consent will remain active for the duration of the student’s enrollment at the school served by the SBHC unless expressly revoked in writing.

Privacy and Confidentiality

In accordance with state and/or federal law, when consent is provided for care, health care information is kept confidential. A few exceptions exist, for example:
- Permission is given by the patient or parent/guardian through a signed release of information form
- The patient indicates risk of imminent harm to self or others
- The patient has a life-threatening health problem and is under the age of 18
- There is reason to suspect neglect or abuse
- Certain communicable diseases must be reported to public health authorities
I hereby authorize that:

{studentsLegal} (DOB: {studentsDate}) may receive services healthcare services that are available from, and deemed necessary by, CHC staff.
Student Signature

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Date

MonthDayYear
Date
Parent/Guardian Legal Name*

First NameMiddle NameLast Name
Relationship to Student
Date

MonthDayYear
Date
Parent/Guardian Signature*

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School-Based Health Center

Registration and Consent Form
Health History

To provide the best care possible, we also ask for demographics and family health history. You have the right to refuse to answer these questions. Your answers will not be shared or used for any purpose other than gathering general demographic information to best serve our patients and community.

{studentsName}

DOB: {studentsDate}
Who is completing Health History?
Date

MonthDayYear
Date
Full Legal Name of Parent/Guardian

First NameMiddle NameLast Name
Does student have a primary care provider?

YesNo
Has student had a well child visit/check-up in the last year?

YesNo
Provider Name/Clinic
Clinic Phone Number
Please enter a valid phone number.
Does student have a dental provider?

YesNo
Has student seen a dentist in the last year?

YesNo
Dentist Name/Clinic
Dentist Phone Number
Please enter a valid phone number.

School-Based Health Center

Student's Contact Information

School-Based Health Center

Parent/Guardian Information

School-Based Health Center

Student Demographics

School-Based Health Center

Insurance Information

Medical Insurance Information

Dental Insurance Information

School-Based Health Center

Release and Consent Signature

School-Based Health Center

Privacy Notice

School-Based Health Center

Release and Consent Signature

School-Based Health Center

Consent for Care

Privacy and Confidentiality

School-Based Health Center

Health History

School-Based Health Center

Health History

Questions about Student