SBIRT Opt-In Form
Dear Parent(s)/Guardian(s),

The Northshore School District (NSD) is working in partnership with the King County’s Best Start for Kids (BSK) initiative to begin a screening and intervention system in middle schools, called Screening, Brief Intervention, and Referral To services or SBIRT. SBIRT will allow the district to proactively support students in building skills to support youth mental health and well-being along with addressing substance use issues.

With your permission, your student can participate in a screening process to assess for the need for SBIRT services. The screening assessment tool used is called the Check Yourself Tool. The Check Yourself tool is an interactive electronic screening tool that gives teens personalized feedback and strategies for staying healthy. It also gives the school support team key information about the student. The goal of the tool is to help spark conversations between teens and their support team that motivate teens to make healthy choices. The tool is a HIPPA compliant, interactive, web-based survey that collects individual student data and provides them with instant personalized feedback about mental health behaviors.

The screening is administered electronically and takes about 10-15 minutes to complete. Questions cover four different areas, including: strengths and goals, substance use, mental health, and personal safety. The screening is designed to determine whether a student may or may not need additional support. Not all students who take the screener will need to speak with a counselor, however, every student who takes the screener will receive personalized feedback. Due to the personal nature of the questions, we have attached them for you to preview before giving consent. Students will also have the opportunity to opt themselves out of the survey at any time.

Your student’s privacy is important to us. Your student’s responses to the Check Yourself Tool will reside on secure servers through Tickit Health. The Northshore School District has a data-sharing agreement with Tickit Health to ensure that the answers your student gives will only be viewed by the school counseling team and SBIRT support staff. Researchers at the University of Washington and King County will only have access to survey data that omits student names, student numbers and any other identifying information.

The information that we collect will be reviewed by the school-based support team. If, through the screening process, your student displays a need for support, you will be contacted to discuss support options.

If you wish to opt in to your student’s participation in this screening, please complete this online form. In order to participate within this program, it is required that the opt out form must be submitted online or to your school counselors, otherwise your student will automatically be opted-out and not receive services related to SBIRT.

Thank you for your cooperation and support.
Students Full Name: *
Student Date of Birth: *
What school does your student attend? *
What grade is your student in? *
Name of Parent/Guardian: *
Parent/Guardian Phone Number *
Never submit passwords through Google Forms.
This form was created inside of Northshore School District. Report Abuse