Effingham Two Way Release – Building Blocks Counseling

Dear Parent/Guardian:

Your student has been referred to the School Counseling Telehealth Program with Building Blocks Family Counseling. This is a collaboration between the Effingham School System and Building Blocks Family Counseling- a mental health private practice with locations in Savannah, Pooler, and Rincon.

How does it work?

A referral will be sent from your student’s school counselor to Building Blocks. You will receive a call from our office to set up an appointment, get insurance information, complete paperwork, etc. An online intake appointment will be scheduled for your student during the school day (based on times provided by the school counselor). An online intake appointment will also be scheduled between your student’s therapist and yourself to gather information regarding your student. The Therapist will schedule routine parent/guardian check-ins with you and family sessions as needed. Sessions with students will generally be weekly (during school hours) and last for 30-45 minutes. Parent/Guardian sessions can be held during or after school hours and last for 45-50 minutes.

Paperwork Needed

In order to provide these services we need the following paperwork completed for each student. A new client intake packet, child/adolescent questionnaire, and a release of information for the school counselor. We will be coordinating sessions with your student through the school counselors at their school so it is important we have the release of information completed.

Appointments

Appointment reminders via email, text, and phone will be sent the day before any scheduled appointments. Please make sure we have the best contact information on file so you will receive all of the reminders.

If you have any questions or concerns please feel free to address these with your therapist. If you feel like your student no longer needs services, please also communicate this with your therapist. For more information on Building Blocks Family Counseling, please go to our website at www.buildingblocks.solutions.

Date*

Client's Name*

First Last

Date of Birth*

Age*

Social Security Number*

Parent/Guardian's Name

(if applicable)

Relationship To Client

Parent/Guardian's Name

(if applicable)

Relationship To Client

Is there a custody agreement?*

Shared
Sole
Joint

Who has legal decision-making power for medical/psychological treatment?*

Primary Guardian's Phone Number*

Address*

Street Address Address Line 2 City State ZIP Code

I authorize a two-way release of records/information between the following Effingham County School and Building Blocks Family Counseling:

Name of School*

Phone*

Counselor’s Name*

Type of Release: This release is to allow the school to openly communicate with the assigned therapist at Building Blocks regarding appointment scheduling and information about your child’s counseling services throughout the school year. Valid For: Current school year ONLY.

Primary Parent/Guardian's Signature*

Date*

Phone

This field is for validation purposes and should be left unchanged.