Service Forms
The Gaylord Youth Support Program provides access to behavioral health therapy for students at Gaylord Intermediate, North Ohio and South Maple Elementary Schools. It is a collaboration between Alcona Health Center, the Health Department and Gaylord Community Schools.
Click below to view/download the paperwork necessary to begin working with Alcona Health Center Behavioral Health Providers. Please contact the provider at your student's school if you need help completing any of these forms.
Parent/Guardian Consent for Treatment - For parents/guardians to complete. This form needs to be completed before we can see your child.
Privacy Practice Notice - Important information regarding your participation in therapy services.
Notice of Privacy Practice Signature Page
Release of Information - Please complete this form to allow us to communicate with other providers, agencies, or individuals that are involved in your student's care.
Alcona Health Department
