School
-
Based
Telehealth
& Teletherapy Grant Application
District/School System Name
*
LEA Number
*
Total District Enrollment
*
Total Full Time Staff
*
What is the current absentee rate for students?
What is the percentage of student enrollment on free and reduced lunch?
Is there a school clinic at each school location?
*
Yes
No
Is there a full time nurse at each school location?
*
Yes
No
If there is no full time nurse, please describe the staff position role who manages the school clinic.
Please describe the existing school clinic program(s). (300 word limit)
*
0/300
Do you have a full time counselor at each school location?
*
Yes
No
Please describe the existing school mental health program. (300 word limit)
*
0/300
Is there currently an acute or primary care telehealth model within the district?
*
Yes
No
Is there currently a mental/behavioral health teletherapy model within the district?
*
Yes
No
Is the school system currently billing for services such as special education, occupational therapy, and speech therapy?
*
Yes
No
Describe your current needs for implementing a telehealth program. (200 word limit)
*
0/200
Elaborate on challenges students face in obtaining health care services. (200 word limit)
*
0/200
Please describe how the school district will promote the new telehealth services throughout the school community.
*
0/200
Please describe the plan for daily utilization of the telehealth program within school clinic and/or counseling services.
*
0/300
Total schools you would like to implement the school-based telehealth grant program?
*
List school name(s) applying for telehealth grant program (List All)
*
First Name of Staff Member Completing Application
*
Last Name
*
Position/Title.
*
Email Address
*
Phone
*
Signature
*
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