Agenda - 09-28-2017 - Attachment A - Chapel Hill Carrboro City Schools

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Memorandum of Agreement: Chapel Hill Carrboro City Schools and MH agency to CHCCS students. Agency shall equip the assigned office space with any necessary computers, printers, fax machines, copiers, and all medical equipment necessary to provide the services. Agency agrees that CHCCS will not be liable for any damage to the assigned space caused by or the result of the Agency's use of the space, or loss of any equipment, supplies or other items provided by the Agency for use in the assigned space. e. Agency will assign at least one therapist per identified school. The determination of the therapist's exact schedule at the school (number of days the therapist will be present at the school, times of day, etc.) will be determined by mutual agreement between CHCCS and the Agency based on the acuity of needs of students on the therapist's caseload at each individual school. f. Agency will be responsible for properly supervising its staff while providing services on CHCCS property. g. All agents or employees of the Agency who will provide services to CHCCS students will be fully qualified, possess any requisite licenses, and otherwise be legally entitled to perform the services provided, and shall exercise the skill and care customarily exercised by duly licensed and qualified providers of the same or similar services. h. Agency will accept student referrals for services as provided by CHCCS. Agency will only accept referrals and provide services to students following the receipt of parental consent for referral and treatment. Agency agrees to work with CHCCS regarding the development of appropriate consent forms and information materials about services offered by the Agency. i. Agency agrees that this is a school-based mental health program and the primary place of service will be in the schools prior to, during, and immediately after school hours. Agency will provide services at specific times determined in collaboration with CHCCS. Agency agrees to provide services to students at times and in a manner that minimizes the amount of disruption to students' academic instruction. Agency further agrees services will be made available during evening hours or during school holidays and breaks on a limited basis based on the student's level of need. j. Agency agrees to make services available to students with publicly funded mental health coverage, private health insurance, state funding, sliding scale, and financial aid. Services will be provided to students based on the benefit selection, according to the criteria for each service and payer source. Agency shall be solely responsible for any necessary billing paperwork. Regardless of any payer source or benefit selection criteria, Agency agrees to provide services to students referred to the Agency regardless of ability to pay. k. Agency will obtain the appropriate background checks and provide appropriate supervision and ongoing training for staff and agents providing services to CHCCS 21Page CHCCS CO-LOCATED MENTAL HEALTH SERVICES Department of Exceptional Children's Program and System of Care 2017-2018 8/2017 128