Discovery Charter School Therapy Services           provided by Etika Logika LLC (2022-2023)
[Providing Therapists: Stephanie Henschen, LCPC (Hillpointe Campus) / Elissa Lafranconi, LCPC (Sandhill Campus) *Elissa Lafranconi, CPC-Intern is under the Clinical Supervision of Stephanie Henschen, LCPC)].

To contact us directly please email:    schoolprograms@etikalogika.com
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Email *
BENEFITS/RISKS: There may be both risks and benefits associated with participation in counseling. Counseling may improve my child’s ability to relate with others, provide a clearer understanding of himself/herself, along with values, goals, and an ability to deal with everyday stress. Counseling may also lead to unanticipated feelings and change, which might have an unexpected impact on my child and his/her relationships.
CONFIDENTIALITY: In order to build trust with the child, the school counselor will keep information confidential with some possible exceptions. The counselor may share information with Discovery Charter School's administration, staff, and teachers, but only as it is necessary to the well-being or better education of the child. Any information given by the counselor regarding the student to the parents/guardians, the child’s teacher, and/or administrators or school personnel who work with the child on a need to know basis, so that we may better assist the child as a team. The counselor is required by law to share information with parents or others in certain circumstances: Presenting a serious danger to self or another person, Evidence or disclosure of abuse (physically or sexually) or neglect, Threats to school security, Criminal or delinquency proceedings are pending. The counselor will make the child aware of these limits of 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.  *For Parents that are separated/divorced, both parents will receive this form. **Counselors will not be able to testify in court for any custody related issues. *
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CONTACT:  I am entitled to ask questions and receive information about methods or techniques used by the counselor and the length of counseling, but not about the content of actual sessions. I am free to seek a second opinion or end counseling at any time. I also understand that any contact between with the counselor with the use of technology such as email or by phone cannot be considered 100% confidential. While the counselor will keep confidential any information that is shared via email or phone, technology comes with its own risks that cannot be guaranteed (I.e. hacking, virus, etc...). *
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Which Campus does student attend?
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Student's Name *
Student's Date of Birth:
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Are parents of student divorced or under any specific custody protocols?
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Parent/Legal Guardian's Name *
Email *
Address *
Phone number *
Parent/Legal Guardian's Name (If parents are separated/divorced)
Email
Address
Phone number
Student's Homeroom Teacher:
By signing this form, I certify that I have read and agree to this consent form.  (Parent /Legal Guardian Signature:) *
Date
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Comments/Special Considerations about Student:
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