Wellness & Counseling Team  

I have been told about wellness and counseling services available. I understand that: 

• The Wellness & Counseling team may consist of providers from within the San Jose Conservation Corps Charter School (“SJCCCS”) and from outside community partners. The SJCCCS team includes school counselors, success navigators, and may include other mental  health support staff who work with SJCCCS such as psychologists and social workers. The team may also  include mental health, substance abuse, and/or other behavioral health counselors who work for different community organizations, managed care plans or the county behavioral health department and have signed agreements with SJCCCS. 

• Wellness and Counseling services may include health assessment, referrals to other providers, case management, counseling/therapy, and/or other wellness support. Services can also include mental health or substance use counseling, anger management  counseling, grief counseling, support and empowerment groups, skill-building, and social-emotional groups or other healthcare  support. 

• Some of the healthcare team members may be trainees working toward undergraduate or graduate degrees in psychology, social  work, marriage and family therapy, nursing, and/or psychiatry. These trainees will be supervised by a credentialed, associated or  licensed staff. 

• I understand that mental and behavioral health services may be provided in-person or via telehealth during the school day.

• I understand that my health insurance may be billed for the services I receive at school and I consent to Medi-Cal, commercial  and private insurance for these services.  

• I understand that these services are free to me; neither the school nor my insurance provider will charge me a co-pay or fee. 

 

Privacy 

• I have been told about how the Wellness and Counseling Team will protect my privacy and keep my health information private. I have  been offered a copy of the Wellness & Counseling Notice of Privacy Practices, which has information about how my private health  information may be used and disclosed under the law. I understand that in certain situations information must be disclosed; for  example, if there is a reasonable suspicion of child abuse. We may also disclose information about you when necessary to  prevent or lessen a serious threat to your health and safety, or to the health and safety of the public or another person. A  disclosure would only be to a person or persons reasonably able to prevent or lessen the threat.  

 

Sharing Information with Others  

I understand that the Wellness and Counseling Team: 

• Will share my private healthcare information with each other for the purpose of coordinating and evaluating my care. 

• May share my private healthcare information with healthcare professionals other than the Wellness and Counseling Team in order to better provide  services to me.  

• May talk to school officials, including  other support staff, administration, and teachers, on a need to know  basis about whether or not I am receiving services. This will make it easier to remind me of my appointments, to excuse me from  class, and/or to confirm referrals to the Wellness and Counseling Team. General information about my participation in wellness and counseling activities also be shared in Student Success Team meetings, or meetings of a similar nature. 

 

• May disclose personal identifiable service data with contracted, state or federal program evaluators for research, evaluation, and  for continued funding for the program.

• Will always ask for your consent before sharing any additional information beyond what is stated above.

 

NOTICE TO CLIENTS  

Wellness Client Records 

I have been told that: 

• My mental and behavioral health records will be securely stored, either physically or virtually, in a separate location from the rest of my  education file. 

• Parents/legal guardians have a right to request a copy of their minor child's education record, and that the mental and behavioral health records could be considered part of the education record. The Wellness and Counseling Team will do everything they can to protect my privacy.  

• Client records created by community-based healthcare providers on-site at my school are not considered to be part of my  education record, and would therefore not be released by the school as part of my education record.  

• I can revoke this consent at any time by notifying the Wellness and Counseling Team in writing. 

• This consent form is valid for one year. A new consent form is required annually.

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Filing a Complaint: 

Beginning July 1, 2020, all mental health counselors, whether licensed or unlicensed, are required to provide a notice to each of their  clients regarding where they can file a complaint (AB 630, Chapter 229, Statutes of 2019). 

The Human Resources Department at SJCCCS receives and responds to complaints regarding the practice of counseling and therapy by any SJCCCS unlicensed or unregistered practitioner providing services in school based wellness & counseling program. To file a complaint, contact Jasmine Fuentes, HR director at jfuentes@sjcccs.org. The California Board of Behavioral Sciences receives and responds to complaints regarding services provided by individuals licensed and registered by the board. If you have a complaint and are unsure if your practitioner is licensed or registered, please contact the Board of Behavioral Sciences at 916-574-7830 for assistance  or utilize the board’s online license verification feature by visiting www.bbs.ca.gov. 

 

The Board of Behavioral Sciences may also addresses complaints for licensed practitioners:  

The Board of Behavioral Sciences receives and responds to complaints regarding services provided within the scope of practice of  marriage and family therapists, clinical social workers, licensed educational psychologist or professional clinical counselors. You may  contact the Board online at www.bbs.ca.gov, or by calling 1-916-574-7830.