Registration Forms
Parent Registration Forms
Parental/Guardian Permission Form Concerning Treatment
Consentimiento De Los Padres/Tutores Legales Para Recibir Tratamiento
To enroll in an Integrated Health Services School Based Health Center, or to refer a student who is currently enrolled in a participating school for services, select and complete from the forms below. Once submitted, forms will be sent directly to a Program Administrator for follow-up.
School Based Health Center Forms
- CHOOSE A FORM
- Parent Permission Form (English)
- Formulario de Permiso para Padres (Español)
- HIPAA Acknowledgement Form (English)
- Formulario de Reconocimiento de HIPAA (Español)
- IHS Authorization for Release of Information (English)
- Autorización de IHS para la divulgación de información (Español)
- Referral Form
Jesse has worked in the Healthcare industry since 2003, primarily in the medical device space. He has direct experience in device management across a wide portfolio of technologies including medical imaging, general biomedical, and surgical instruments. Hands on experience leading teams focused on maintenance, device tracking, lifecycle management and capital planning for replacement. He has held national roles overseeing supply chain, logistics, contracting, pricing/marketing, customer contact center, and a wide range of back off support functions.
Christopher Sour is an Investment Analyst currently working at CVS Health. As an alumni of the CVS Financial Leadership Development Program, Chris has worked in Internal Audit, Corporate Treasury, and Investment Management. In his current role, Chris aids in the management of hedge fund, CLO, equity portfolios, and pension plan assets. Responsibilities include making new investments across the asset classes, managing risk, on-going monitoring of investments and allocating capital across the asset classes.
Jeff Walsh is a graduate of Babson College in Wellesley, MA, with a degree in Accounting. Prior to joining CRT as their CFO, Jeff worked in public accounting for 19 years, specializing in non-profit and governmental audits throughout the northeast region. Jeff has extensive experience with the Federal Single Audit and State of Connecticut Single Audit requirements, in addition to Form 990 preparation and indirect cost rate calculations. 
James Cornell is the Senior Manager of Accounting Compliance at Hartford Steam Boiler. For the last 17 years, he has provided his assurance and financial analysis experience to healthcare and insurance entities in Connecticut. He joined the IHS board in May 2023.
Dr. Saunders is a staff psychologist working at the Institute of Living/Hartford Hospital and is also Board Certified in Clinical Psychology. She is the Director of the new initiative, the Center for Gender Health at Hartford Healthcare. In 2015, Dr. Saunders was named Employee of the Year for Hartford Hospital and in 2019, she was the recipient of the Ned Graffagnino Award for distinguished service in the areas of community-oriented work and collaboration with other mental health professionals. Her areas of expertise include LGBTQ mental health, child psychopathology, behavior management, parent training, and family therapy. She appears regularly in local TV news to provide psychological input on topics relevant to youth and families and currently has two weekly segments on WFSB/Ch. 3 Great Day CT, related to child mental health. 
Stephanie Begen retired in 2021 after 44 years as an educator in the greater Hartford region. She began her career as an elementary Special Education Teacher in Hartford and wrapped up the last 22 years of her career as a middle school Special Education Teacher in Berlin. Along the way she also worked at the Capitol Region Education Council, the University of Connecticut, Division of Child and Family Studies, and at Newington Children’s Hospital as a Patient/Team Coordinator for the PEDAL program. Stephanie was a passionate educator working with families/caregivers, service providers and outside agencies to ensure that her students’ educational, emotional, and healthcare needs were met. 
Yanira Nazario is a Universal Banker at M&T Bank, with over 15 years of experience in banking. She is passionate about the community she serves and dedicated her time volunteering in and around Hartford County. 
Nestor Leon has over 25 years of workforce development experience. He has designed, implemented and monitored programs that provide pathways to economic self-sufficiency. He has coordinated programs in multiple states such as Connecticut, Massachusetts, Rhode Island, New York, and Virginia that resulted in improved access for low-income customers. He is currently working with the Connecticut State College and Universities (CSCU) on a 35-million-dollar statewide healthcare and social work initiative.
Dr. Andrew Feller is a Family Physician who currently works with Trinity Health of New England. For the last 20+ years, he has split his time working as a family doctor in East Hartford, taking care of hospitalized patients at St. Francis Hospital, and teaching residents and medical students at University of CT in Farmington. 
Matthew Cholewa is an attorney with over 30 years of experience. Matt has spent about half his career in private practice and half in the title insurance industry and is currently employed with Old Republic National Title Insurance Company as First Vice President & Senior Underwriting Counsel for its Commercial Agency Services office based in Hartford, Connecticut. While in private practice, Matt’s practice consisted of commercial and residential real estate transactions, real property related litigation, zoning, tax appeals and other small business matters.
Joe Murphy is a Certified Financial Planner™ at Gateway Financial Partners. He has over 40 years of experience in Wealth Management and Investment Planning, including working with teams in the bank investment arena. 
Kareen Wilson is a team leader, owner, and patient-therapist at Contemporary General Dentistry in West Hartford, CT, and Smile Studio Dentistry in Hartford, CT. Kareen also works as an adjunct professor in the leadership program at Goodwin University. She has over twenty-five years of experience in clinical dental hygiene and office management. 
For over 25 years Doug Edwards has been a family services consultant who designs and facilitates fatherhood-focused programs. He provides professional development and training for family workers at state and non-profit human services agencies.