CHILEDA INSTITUTE, INC.
EMERGENCY MEDICAL CONSENT OF PARENT OR GUARDIAN
Student Name:Birth Date:
I, hereby CONSENT to the provision by
(Parent or Guardian)
Chileda Institute, Inc. of ordinary medical and dental, and emergency medical, dental, and surgical care,
recommended by a qualified physician.
______
Student SignatureDate
Parent or Guardian Signature Date
Chileda Institute, Inc. agrees:
- To notify the said parent or guardian of any serious illness, special treatment, or hospitalization needed by, and recommended for, the child by a physician or surgeon licensed to practice medicine and surgery, and also of special dental treatment.
- To obtain consent of the parent or guardian for any surgery recommended by a surgeon, except in the case of emergency surgery.
- In the event of the need for emergency surgery, to exert reasonable effort compatible with the nature and time limitation of the emergency, to secure the consent of the said parent or guardian. When this is not possible, Chileda Institute, Inc. will make effort to notify the parent as soon as possible after the surgery, of its occurrence, and the circumstances.
- To obtain parental or guardian consent prior to making modifications to said child’s psychotropic medications, unless the situation is deemed medically necessary due to an emergency situation, is ordered by a licensed physician, and Chileda Institute, Inc. is unable to contact the parent or guardian.
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Chief Executive Officer, Chileda Institute Inc.Date
______
Director of Family Services, Chileda Institute, Inc.Date
______
Director of Health Services, Chileda Institute, Inc.Date
Student Name:Birth Date:
Chileda Off-Campus Medication Policy
Please read the enclosed off campus medication policy and sign indicating you are aware of Chileda’s policy. If your child does not take seizure medications please initial and date at the bottom.I am aware of Chileda’s off-campus policy regarding non-scheduled (PRN) seizure medication not being sent on recreational or classroom outings within 20 miles of the Chileda campus. I am aware that 911 will be called for any situation that Chileda staff are not trained to handle safely.
Parent or Guardian SignatureDate
I am aware of Chileda’s off-campus policy regarding non-scheduled (PRN) seizure medications not being administered by Chileda staff members when a student is on a recreational or classroom outing within 20 miles of the Chileda campus.
I grant permission to a Chileda staff member trained in medication administration by Chileda to administer PRN medications for seizures as per the seizure protocol written by me.
Ordering PhysicianDate
Exceptions to this policy will be made only with the approval
ofChileda’sDirector of Health Services
My child is not prescribed seizure medications. ______
Parent or Guardian InitialsDate
CHILEDA INSTITUTE, INC.
MEDICAL PAYMENT RESPONSIBILITIES
FOR RESIDENTIAL STUDENTS
Please provide copies of all private and public insurance information to Chileda Institute, Inc. prior to your child’s enrollment. Chileda Institute does not cover the costs of medical appointments or medications during a child’s enrollment. Chileda Institute provides applicable medical providers with information regarding your child’s medical coverage.
Parents will need to call medical vendors directly (hospital/clinic) with concerns regarding billing and/ or changes and updates in medical coverage.
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As the parent and/or guardian of ______, I acknowledge that Chileda Institute is not responsible for the costs of medical care, medical appointments, and medications for my child, and agree to provide information for processing insurance and/or private pay reimbursement for medical expenses and medications while my child resides at Chileda Institute.
I further acknowledge that the costs of medical care, medical appointments, and medications during my child’s enrollment at Chileda Institute are my parental/guardianship responsibility, and I agree to provide payment for these services and medications as per medical provider billing procedures.
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Parent/Guardian Signature
Name of Parent/Guardian (Please Print)
______
Date
CHILEDA INSTITUTE, INC.
NOTIFICATION OF ROUTINE MEDICAL APPOINTMENTS
Student Name:Birth Date:
Each resident is assigned a pediatrician at Mayo Healthcare Systems andwill receive a routine physical exam within two business days of enrollment at Chileda, as required by our license. Chileda will notify parents/guardian ifthere are any recommendations or concerns after this appointment. Routine physical exams are performed annually.
If your child has established medical care in La Crosse,WI, please indicate the physician’s name and clinic or hospital affiliation here: ______
Written summaries of all medical appointments,including any recommendations or other findings, are provided every 90 days within the Treatment Plan.Chileda’s Health Service Department will document any planned future medical appointments within the Treatment Plan as well. Chileda’s Health Services Department does not routinely notify families in advance of routine medical appointments, unless parents specify.
☐I am comfortable with receiving medical updates for routine medical care (including annual physical exams, vision, audiology, and dental check-ups) at quarterly Treatment Plan meetings; I understand that Chileda’s Health Services Staff will contact me within 24 hours after these medical appointments ifthere is a change to my child’s health status or any recommended changes to his or her medical care.
☐I would like to be notified in advance of the following medical appointments so I may attend or otherwise participate:
☐Dental appointments
☐Annual Physical Examinations
☐Psychiatry Appointments
☐Neurology Appointments
☐Other routine medical appointments (audiology, vision, etc.); please specify: ______
Parent/Guardian (print):______
Signature:______Date: ______
CHILEDA INSTITUTE, INC.
CHILD PERSONAL FUNDS PROCEDURE
Students may receive money from family members for personal purchases outside of what is already provided to them as a resident at Chileda. “Money” is defined as checks or cash.
Chileda does not accept anything other than checks or cash, with checks being preferred. We ask that you as the parent / guardian sign off on a written acknowledgment of the dollar amount (a check would be considered automatic acknowledgement by the signature on the check). If cash is sent through the mail, Chileda Business Office will promptly e-mail the parent / guardian of the receipt and will require you to acknowledge the amount. If you do not have access to e-mail, then Chileda Business Office will mail a hard copy receipt to you for acknowledgement.
This is what a receipt looks like:
We will not be able to accept gift cards and we will return gift cards directly to you as the parent / guardian. If gift cards or other unacceptable gifts (e.g. cash with no receipt of amount) are given to your child, your case manager will return it to you, even if it came from a different source (e.g. a grandparent).
Please note that your child will not be able to carry money on themselves, or keep money in their bedroom. Chileda will hold these funds and make available to the student at the case manager’s request. The case manager will contact you when your child makes a request to purchase a special item for your approval prior to any purchases.
Your child’s personal money will be returned upon discharge. Your case manager will request your child’s personal money when your team has decided upon a departure date from Chileda. Upon a reasonable time after discharge, Chileda will issue a check payable to the student for the remaining funds. The check will be mailed to the known parent / guardian address, unless directed otherwise.
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Parent / Guardian Signature Date
CHILEDA INSTITUTE, INC.
ELECTRONICS AND PERSONAL PROPERTY POLICY
Chileda provides an array of both technological and more traditional recreational and educational items for students who live and learn at our facility. Chileda discourages residential and day school students from bringing any valuable personal property, electronic games and devices, electronics with Wi-Fi capabilities, and/or personal computers or TVs.
Due to the need to maintain confidentiality of all students, devices with photo and video taking capabilities are prohibited; pre-arranged use of i-pads with these capabilities for communication purposes only will be approved on an individual basis.
Chileda will not be responsible for repairing or replacing any personal property or electronic devices that go missing or are damaged or destroyed during your child’s enrollment. If personal property or electronic devices are sent to Chileda with your child, it is done at your own risk and Chileda cannot guarantee it will return in the same condition. We encourage you to have your items insured, as appropriate.
As the parent and/or guardian of ______, I acknowledge that Chileda Institute is not responsible for the costs of personal property and electronic equipment brought to the Chileda campus. I have read the statement above and understand sending personal electronics is discouraged by Chileda and these items will be bought at my own risk.
I further acknowledge that the costs of repairing or replacing personal electronics during my child’s enrollment at Chileda are my parental/guardianship responsibility, and I understand that Chileda is not financially responsible for any items that go missing or are damaged or destroyed during my child’s stay.
Personal items and/or electronics my child will bring to/has at Chileda are as follows:
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Name of Parent/Guardian (Please Print)
Parent/Guardian Signature
Relationship to Child
______
Date
CHILEDA INSTITUTE, INC.
VERIFICATION OF RECEIVING STATEMENT OF RESIDENTS’ RIGHTS
With signature, I verify that I have received a written copy of the statement of residents’ rights your son/daughter will review residents’ rights upon enrollment. The statement of residents’ rights will be read and reviewed with my child in an effort to assist in the understanding and implementation of residents’ rights.
I have also been informed of the existence of the Best Practice committee, and have been provided a written copy of the procedures for reporting violations, concerns, or issues relating to residents’ rights.
Further questions regarding my child’s rights can be directed toward the Director of Counseling and Advocacy, and/or the Director of Family Services.
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Parent or Guardian Signature Date
CHILEDA INSTITUTE, INC.
BEHAVIORAL SUPPORT CONSENT FORM
I, give my consent for
(Parent or Guardian)(Student Name)
to participate in behavioral approaches as outlined in the Behavior Services Departmental Policies and Procedures Manual (excluding use of psychotropic medications). I have received a copy of theBehavior Services Departmental Policies and Procedures Manual and am aware that an oral discussion of this material is available upon my request. I may discuss or raise questions regarding these policies and procedures by contacting the Director of Behavior Services. I understand that consent is voluntary and may be revoked at any time by notifying Chileda Institute, Inc. in writing.
All Behavior Programs are reviewed by Chileda Institute, Inc.’sBest Practice Committee prior to implementation. The Behavior Program will immediately be sent to the parent/guardian for review. Behavior Program approval will also be sought. Behavior Programs and associated behavioral data are also reviewed by Chileda Institute, Inc.’s external Human Rights and Research Committee.
By signing below, I give consent for ______to participate in behavioral
(Student Name)
approaches developed by Chileda Institute, Inc. as outlined in “Behavior Services Departmental Policies and Procedures” manual.
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Parent or Guardian Signature Date
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Director of Behavior Services Date
PARENTAL CONSENT FORM
Name of Student: ______Birthdate: ______
Medication
I consent to Chileda staff administering my child’s medication and over the counter medications listed by the physician. Medication will be supplied in original, properly labeled containers. I will notify Chileda in writing with any changes in medications or with changes in my child’s medical condition. I will obtain updated physician orders for any changes that occur. I authorize Chileda’s medical personnel to contact my child’s physician if needed. I release Chileda of any liability claims as a result of the administration of medication or procedures as directed.
Parent’s Signature ______Date:______
Program
I hereby state that I am aware of and accept the risk inherent to my child participating in programming with other children and young adults who demonstrate severe behavior and learning disabilities. The undersigned does hereby agree to hold harmless and indemnify the Chileda Institute, the Board, and employees from any and all liability, loss, damages, costs or expenses which are sustained, incurred or required arising out of my child’s participation in Chileda programming.
Parent’s Signature ______Date: ______
Field Trips and Transportation
I give permission for my child to participate in walks, community activities, sports, field trips, swimming, roller skating, biking, and other school activities related to educational and recreational curriculums and treatment plans. I also give permission for Chileda to transport my child to these events in Chileda vehicles.
Parent’s Signature ______Date: ______
House and Classroom Moves
On occasion your child will be confronted with moving from one house or classroom to another. Moves are motivated by many factors including student’s progress, age changes, behavior supports needs, and enrollment issues. Changes in classrooms or houses are accompanied by structured events and other activities to ensure smooth and positive transitions for the students.
I give permission for my child to transfer from his or her house or classroom to another as deemed appropriate by Chileda staff. I will be informed of all moves.
Parent’s Signature ______Date: ______
Haircuts
☐ I give permission for my child to receive haircuts as needed.
☐ I will provide for my child’s haircut needs.
Please note any special requests:
Parent’s Signature ______Date: ______
CHILEDA INSTITUTE, INC.
COMMUNICATION POLICY
COMMUNICATION
Parents are encouraged to maintain on-going contact with their child and their child’s Case Manager. If you are unable to reach your case manager please contact the Director of Family Services. Chileda will always notify parents and social workers in the event of a serious incident or medical emergency.
Communicating with your child:
- Please arrange a visitation plan, phone contact plan and Skype (video-conferencing) schedule with your child’s Case Manager.
Communicating with the Case Manager:
- Chileda’s Case Management staff are the primary point of contact for parents and social workers. Parents should establish a scheduled time to communicate with the Case Manager via phone or e-mail at a minimum frequency of twice per month. Case Managers are not available for daily phone calls; phone calls should be limited to 30 minutes per call outside of Treatment and IEP Team meetings.
- Chileda requests that you have phone contact with your child’s Case Manager during business hours. If you are calling outside of business hours your main contacts will be either the Medical Staff or Shift Supervisor.Due to responsibilities with resident care, supervisors and medical staff will have time- limited availability to talk with parents. Chileda does not allow phone or e-mail contact with direct care staff as this is a distraction from the primary responsibility of safety and supervision of the residents at Chileda.
- If calling after business hours and a Medical Staff or Supervisor is not available please leave a message at extension 227 and they will return your call as soon as possible.
Communicating with Treatment Team Members:
- Parents are encouraged to maintain on-going contact with their child’s Teacher, as well as with our medical department, behavior specialist, and counselor as appropriate. We encourage parents to establish a scheduled time to communicate via phone or e-mail (at your convenience) with these members of the treatment team. Please carbon copy (“cc”) the Case Manager when contacting other members of the Treatment Team.
CHILEDA PARENT COMMUNICATION FORM
Date:
Name of Resident:
Name of Parent(s)/Guardian:
COMMUNICATION WITH CHILD:
Preferred method of contact:___Phone: (number)______
___Skype
___letter: (address)______
______
Preferred frequency of contact:___daily: (phone only)
___3-4x/week (method)______
___2-3x per week (method)______
___1x per week (method)______
___every other week (method)______
COMMUNICATION WITH CASE MANAGER:
Preferred method of contact:___Phone: (number)______
___e-mail: (address)______
___letter: (address)______
______
Preferred frequency of contact:___1x per week
___every other week
Days and Times (between 9AM-5PM) that you are available to communicate with the Case Manager:
Monday:Tuesday:Wednesday:
Thursday:Friday:
COMMENTS/NOTES:
VISITING YOUR CHILD AT CHILEDA
POLICY AND PROCEDURES
At Chileda, we encourage families to visit their children and want every family visit to be as successful as possible. To help visits be as enjoyable as possible and provide consistency to each child’s day, this policy was developed.
Confidentiality
For the safety and protection of your child and all students who live and learn at Chileda, HIPAA (Health Insurance Portability and Accountability Act) as well as safety measures and internal protocols, are followed. Chileda is mandated to follow HIPAA, as we must preserve the privacy and guard the confidentiality of health and other confidential information for all residents. Every individual receiving services at Chileda expects that confidentiality of information is maintained.
Planning your visit
- Please arrange a visitation plan and schedule with your child’s Case Manager. Providing advanced notice allows us to prepare your child, their medications and belongings, and to develop support strategies to make your visit positive.
- Chileda will work with families on an individual basis to facilitate meaningful and enjoyable visits.
- Chileda recommends a period of initial adjustment of a minimum of 2 weeks prior to visitation and a minimum of 4 weeks prior to any off campus or home visits.
- Please communicate with your child’s Case Manager to discuss needed supports (such as a calendar, social story, and/or visual schedules) for on and off campus visits. Chileda does not provide staff members for off campus visits. If a behavioral situation arises while off campus, you may call Chileda for phone consultation, however we are unable to send staff to assist. If an emergency situation arises, we encourage parents to call 9-1-1 if the situation warrants. Chileda staff will confer with the responding emergency personnel to assess if your child can be transported back to our campus.
- If siblings come to campus, they must remain under parental supervision, in the area designated for the visit, at all times and maintain confidentiality.
- When returning from a visit, plan to remain present while Chileda a staff unpacks your child’s bag so that we may immediately return any items to you that are not allowed on campus.
- Preferred visiting hours are Monday-Friday 4PM-7PM and Saturday and Sunday 10AM-7PM. Chileda strongly discourages on or off campus visits during scheduled school hours (8:15AM-3:15PM, Mondays-Fridays).
- Chileda requires that all visitors read and sign our “Confidentiality” statement in our Visitor Register. You will be asked to sign a confidentiality form at the time of your child’s enrollment. All visitors who come beyond the reception area will be asked to sign a confidentiality agreement at the time of each visit.
- The front door is the only access into the campus for visitors. Once you sign in, the supervisor will accompany you to your child, or staff will be notified to accompany your child to the reception area.
- To maintain confidentiality of all residents and staff at Chileda we rely heavily on our visitor’s integrity. If at any point Chileda staff feel a visitor is violating confidentiality or disrupting programming, Chileda will restrict visits to assigned areas of campus or implement other interventions necessary to maintain confidentiality and privacy.
- During non-school hours, your visit on campus will take place in the education building as houses are used for programming. If you have brought a gifts or item for your child, a staff member will gladly deliver it to the house for you.
- If you would like to visit your child’s bedroom, you may schedule a visit with the case manager.
- Photographs, videos and other recordings are not allowed without prior approval. If you’d like to take photos, please arrange this with your case manager.
What to expect when visiting your child during nonbusiness hours: