Application for Student Programs for Charlotte-Mecklenburg Schools

Student Name *

First

Last

Student Grade *

School Name *

Insurance Company Name *

Please select your child's primary insurance plan from the list below. This information is required to process billing for participation in our program. If your plan is not listed, please select "Other" and a team member will contact you.

Member ID (Policy Number) *

Parent/Guardian Name *

First

Last

Parent/Guardian Email *

Confirm Email

Parent/Guardian Phone *

Application for Student Programs for Charlotte-Mecklenburg Schools *

Reason for Application / Additional Notes

Parent/Guardian Consent *

I have read and understand the information above. I give permission for my child,

Participate in school-based social-emotional learning (SEL) groups. Engage in services provided by an MSW clinical intern under supervision.”

Consent for Billable Therapeutic Services: *

YES, I give permission for the approved agency to use my child’s basic information to seek reimbursement through my insurance for the services described. I understand this is at no cost to me and is not a condition of my child's participation.
NO, I do not give permission for the agency to seek reimbursement through insurance. I understand this decision does affect my child's ability to participate in the program.

Participate in school-based social-emotional learning (SEL) groups. Engage in services provided by an MSW clinical intern under supervision.”

Parent/Guardian for Member

Signature *

Clear Signature

Custom Captcha *