Mount Pleasant Middle School Universal Opt-In Consent for Student Support Services  
Parental Consent for Supportive Services
Sign in to Google to save your progress. Learn more
Email *

Dear Guardian,  

 A new North Carolina state law, SB 49, requires annual written notification regarding school mental health services.

This form offers you the opportunity to "opt-in" to such services as delivered by school Specialized Instructional Support Personnel (SISP) staff, which include school counselors, school psychologists, school social workers, and school nurses.

The main priority of your child’s SISP team is to empower students to reach their highest level of success - whether that’s in the classroom, on the playground, or in a future career.

SISP members strive to meet the needs of all of our students by visiting classrooms, working with small groups, and meeting with students to discuss age-appropriate topics such as getting along with others, staying safe, coping skills, and learning how to be a successful student.  

Your choice to "Opt-In" will allow the SISP team to provide these support services to your child. Guardians will be contacted if additional resources or services may be beneficial. If you have any questions or concerns about this information, please contact a member of the SISP team. 

 *
Agreement/Consent for Services

I am authorizing SISP staff to provide ongoing supportive individual and/or group interventions for my child.

I understand I will receive regular updates on provided services, progress toward goals, and information on additional resources if a higher level of support is warranted. 

I recognize that services delivered by school staff are not intended to be a substitute for mental health services offered by outside community providers.

I reserve the right to waive this consent at any time by contacting the school staff in writing.  

This consent will become effective from the day it is received by the school and will remain in effect for the school year unless the consent is rescinded in writing by his/her parent or legal guardian. Consents will not transfer from school to school. A new consent form will need to be completed each time your child changes schools. 

I understand that parental or legal guardian permission is required for ongoing supportive individual and/or group interventions. 

 *
Please type in your child's first name. *
Please type in your child's last name. *
Please type in your child's grade level. *
Verification

Please accept my typed name in the box below to serve as my electronic signature authorizing SISP staff to provide ongoing supportive individual and/or group interventions for my child. *
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This form was created inside of Cabarrus County Schools. Report Abuse
Google Forms