Patient intake

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Please complete the patient information form below. If the patient is a minor, the parent or legal guardian must also provide their information in the designated section below.

This section collects information from the parent, legal guardian, or responsible party to verify insurance coverage and ensure proper consent for a minor or dependent’s care.

This form provides consent for the student to receive mental and behavioral health services from GLC Wellness Center staff. Services may include mental health assessment, diagnostic evaluation, individual or group psychotherapy, crisis intervention, psychoeducation, skill-building, case management, and service coordination. Services may be provided in person or through telehealth at the school or another GLC-approved location.

Consent may be withdrawn at any time by submitting written notice to GLC Wellness Center. Withdrawal does not affect services already rendered.

This form affirms that the individual signing is the legal parent or guardian authorized to consent to treatment under Illinois law (740 ILCS 110/4).
Illinois law allows minors aged 12 or older to consent to a limited amount of outpatient counseling without parental consent when clinically appropriate, though parental involvement is encouraged whenever possible.

Telehealth services may involve the use of video, audio, or other secure electronic platforms. Clients are informed of the potential risks and limitations of telehealth, including possible technical interruptions or reduced privacy.
By signing this form, the parent or guardian authorizes GLC Wellness Center to provide services using HIPAA-compliant telehealth platforms.

GLC Wellness Center staff may collaborate with Chicago Public Schools personnel, including teachers, counselors, social workers, and nurses, to ensure care coordination and support the student’s educational progress. Information shared will be limited to the minimum necessary in accordance with HIPAA and FERPA.

Clients have the right to receive and review GLC Wellness Center’s Notice of Privacy Practices, which explains how personal health information may be used and disclosed for treatment, payment, and healthcare operations.

Key HIPAA Rights:

The right to access and request copies of health records,
The right to request restrictions on disclosures,
The right to request corrections to health information,
The right to receive notice of certain disclosures made without consent,
GLC Wellness Center may disclose information without consent when required by law, including emergencies, suspected abuse, or threats of harm.

Information shared during services is confidential, except when disclosure is required by law in cases of:

Suspected abuse or neglect of a child, elder, or dependent adult,
Threat of harm to self or others,
Court orders or legal mandates,
Specific minor consent provisions under Illinois law that restrict parental access to certain details.
 

GLC Wellness Center is authorized to bill Medicaid, commercial insurance, or the appropriate school-based funding source for services provided. Limited information may be released to process such claims. Parents or guardians will not be personally responsible for school-based services unless otherwise notified.

GLC Wellness Center may exchange relevant treatment information with Chicago Public Schools, primary care providers, or other healthcare or support professionals involved in the student’s care, solely for treatment coordination and service continuity.
This authorization remains valid for one year from the date of signature unless revoked earlier in writing.

Clients and families have the right to:

Receive services in a respectful and nondiscriminatory environment,
Refuse or discontinue services and be informed of potential risks,
Participate in treatment planning,
File complaints or grievances without retaliation,
 

In the event of a behavioral health emergency during school hours, GLC Wellness Center staff may collaborate with the Chicago Public Schools Crisis Intervention Team and designated emergency contacts to ensure the safety of the student.

By signing this document, the parent or guardian acknowledges receipt of GLC Wellness Center’s Notice of Privacy Practices, understands the nature of services provided, and consents to treatment and information sharing as outlined above.