ACES SCHOOL BASED SOCIAL WORK

INFORMATION SHEET

Date:______Home School District: ______

Homeroom Teacher’s Name & Email:______

Student Name:______D.O.B.:______Age: ______

Gender: o Male o Female Grade:______

Address:______City ______Zip ______

Primary Parent/Guardian Information:

Name:______Relationship: ______

Home Phone Number:______Cell Phone Number:______

Email Address:______

Secondary Parent/Guardian Info:______

______

District/Building Contact Person:______

Check & Connect Mentor: ______

ACADEMIC RISK FACTORS:

o 1 F and/or 2 D’s per grading period o IEP or 504 – eligibility area ______

o Retention: Grade ______o Previously dropped out o Previous alternative school placement

BEHAVIORAL/SOCIAL RISK FACTORS:

oDiscipline issues? List ______

o DSM-IV Diagnosis ______oMedications ______

o Attendance issues ______

ADDITIONAL FACTORS:

oJuvenile Office oDivision of Youth Services oChildren’s Division oAlbany Regional Center

oFamily Guidance oPrivate Counselor oSafe Schools Violations oWeapons Violations

oDrug/Alcohol Violations oCriminal Offenses oEarly adult responsibilities (excessive work hours, parenting, etc)

oOther ______

o Has child currently in Children’s Division custody or have they been in the past? ______

TARGET CONCERNS/ADDITIONAL COMMENTS/NOTES:

1)______

______

______

2)______

______


AUTHORIZATION FOR DISCLOSURE OF EDUCATIONAL INFORMATION

I, ______(Parent, Guardian, Legal Representative), authorize the exchange, disclosure or release of information on:
______(Student), SS# ______, DOB______between the following entities (This allows both parties to provide and receive information from one another):
______(school district) ACES
______(address) 1212 A S. Main
______Maryville, MO 64468
______(phone) 660-582-3768
THE PURPOSE OF THIS DISCLOSURE IS:
x To share/refer information to obtain services consistent with the ACES program
THE SPECIFIC INFORMATION TO BE DISCLOSED/RELEASED IS (CHECK ALL THAT APPLY)

x Educational Records x Exchange of information via telephone/email

1. / READ CAREFULLY: I understand that my educational information records are confidential. I understand that by signing this authorization, I am allowing the release of my educational information.
2. / This authorization includes both information presently compiled and information to be compiled during the course of treatment at the above named facility or agency paying for services during the specified time frame.
3. / This authorization becomes effective on:
4. / I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so IN WRITING and present my written revocation to the school administrator or ACES social worker at the facility. I further understand that actions already taken based on this authorization, prior to revocation, will not be affected.
5. / I understand that I have the right to receive a copy of this authorization. A photographic copy of this authorization is as valid as the original.
6. / I understand that authorizing the disclosure of this educational information is voluntary. I can refuse to sign this authorization.
Signature of student: / Date:
Witness: / Date:
Signature of Parent/Legal Guardian/Representative / Date:

*Must also have the Informed Consent Contract signed for Social Worker to work with student.*


ACES SCHOOL SOCIAL WORK

INFORMED CONSENT CONTRACT

Name of Student ______

Confidentiality: Please understand that all records, written information, or any electronic data are kept CONFIDENTIAL. All school social work services are confidential, except those required by law to report, which include the following:
-- threats of harm to another or oneself
-- domestic violence
-- child or elder abuse
-- by court order

The other exception would be when a signed release has been obtained to provide or receive information from another entity.
School social work services are focused on assisting with concerns and behaviors of a student that could impede their success. These may include individual sessions as well as group sessions, observations, collaboration with staff, and intervention strategies. You have the right to end this service at any time. The school social worker has a form available if you decide to discontinue this service. These services will continue until revoked by the parent or discontinued by the school.

As a social worker, I participate in case consultations and supervision in accordance with accepted professional behavior.
In counseling children or adolescents, confidentiality is a necessity; as much as possible, in order for the therapeutic process to work. While you as parent or guardian have a legal right to information, I will speak with you in a general way unless there is a danger to the child’s life. This is conveyed to the child as well.

Permission to treat: I acknowledge that it is my choice to have my child participate in school social work services.

Your signature acknowledges agreement and understanding. Please feel free to contact the social worker regarding any questions or concerns you may have.


______
Signature of Parent Date
______

Signature of Student Date


______

Signature of School Social Worker Date

*Must also have the Authorization for Disclosure of Educational Information signed for Social Worker to work with student.*

Revised 5/21/14