Informed Consent for School Counseling

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Dear Parent/Guardian,

Throughout the school year, counselors offer short-term individual and small group counseling to students. Parents/guardians or school staff may refer students for counseling, or students may request counseling. For counseling that extends beyond one session in a school year or that is planned on a regular basis, parent/guardian permission is to be obtained. If your student will be taking part in counseling on a regular basis, please return this form to your school’s counselor.

By signing this form, you are acknowledging that you understand that:

o School counseling services are short-term services aimed at effective academic supports, social-emotional learning supports, or post-secondary planning supports.
o These services are not intended as a substitute for diagnosis or treatment for any mental health disorder.
o It is your responsibility to determine whether additional or different services are necessary and whether or not to seek them for your child.

Although the school counselor may share information with parents/legal guardians, In order to build trust with your child,the school counselor will keep information confidential, with some possible exceptions. Please be aware that:

o The school counselor will abide by FERPA (20 U.S.C. § 1232g; 34 CFR Part 99) rules for student confidentiality.
o The school counselor must take action if he or she feels your child is in danger of harm to self or others. Every effort will be made to work with you and inform you first in such an instance.
o The school counselor must report to law enforcement or an appropriate child welfare agency any time he or she reasonably believes the child is or has been the victim of abuse or neglect.
o The District must comply with court orders for counseling records. If counseling records are ordered to be provided to a court, the school counselor will contact you first in order to give you an opportunity to object to the court order.

The school counselor will make your child aware of these limits to confidentiality and will inform the child when sharing information with others. If you would like the counselor to share information with a third party, such as a community counselor, psychiatrist, social services worker, or pediatrician, you will need to sign an additional release of information form.

Student's Last Name *

Student's First Name *

Grade *

Teacher *

Please select one: *

I give permission for my child to receive school counseling services this school year. I understand that I may withdraw my consent at any time by signing and dating a written note requesting termination of counseling services.

I choose to decline school counseling services for my child at this time. I understand that I may request counseling services at a later date if needed.

Required

Affirmation

By adding my digital signature below, I am affirming that I am the legal parent/guardian of the above named student and I have read and agree to the terms of this informed Consent for Counseling form.

Parent/Guardian Last Name *

Parent/Guardian First Name *

Date *

YYYY

Phone Number *

Email Address *

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