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School Provided or Sponsored Mental Health Services OPT-IN Form (for students under the age of 14)
Vestavia Hills City Schools provides and sponsors mental health services ranging from awareness and prevention to intervention and support. You may request to review any materials used in the guidance and counseling programs available to students by contacting the student's principal or school counselor.
Under Alabama law, no student under the age of fourteen (14) may participate in ongoing school counseling services including, but not limited to, mental health services, unless (1) the student's parent or legal guardian has submitted a written OPT-IN granting permission for the student to participate or (2) there is an imminent threat to the health of the student or others.
If your child is under the age of 14 years old and you wish to give permission for your child to participate in mental health services, please complete the OPT-IN form below.
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* Indicates required question
Email
*
Your email
Student's Legal First Name
*
Your answer
Student's Legal Middle Name (if applicable)
Your answer
Student's Legal Last Name
*
Your answer
Student's Date of Birth
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MM
/
DD
/
YYYY
Student's School
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Choose
Vestavia Hills Elementary Cahaba Heights
Vestavia Hills Elementary Dolly Ridge
Vestavia Hills Elementary East
Vestavia Hills Elementary Liberty Park
Vestavia Hills Elementary West
Liberty Park Middle School
Louis Pizitz Middle School
Vestavia Hills High School Freshman Campus
Vestavia Hills High School
Is your child under the age of fourteen (14) as of today's date?
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Yes
No
I hereby give my permission for my child to participate in the following mental health services. (You may rescind permission for your student to participate in mental health services at any time by visiting the school counselor's office and completing a Mental Health Opt-Out Form.)
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[Check the box for each service you want to be available to your child]
Large-group guidance - includes a school counselor or professional visiting the classroom to discuss standards-based topics such as bullying, class scheduling, stress management, test anxiety, or guest speakers to discuss good choices, substance abuse prevention, etc.
Small-group guidance - includes small groups of students with a school counselor or professional to discuss topics such as test anxiety, grief, healthy coping skills, positive decision making, etc.
Assessments or Surveys - includes counselor-developed needs assessments and questionnaires provided to students related to social behaviors, feelings, etc.
Crisis intervention - short-term, immediate assistance by school counselor, district social worker, or other professional including, but not limited to, IMPACT Family Counseling, Bradford Health Services, etc., for a specific situation.
School-Based Mental Health - ongoing counseling services through IMPACT Family Counseling or other practitioners contracted by Vestavia Hills City Schools in the school setting. Parent or legal guardian permission will be obtained prior to services.
Required
Parent's or Guardian's Signature
*
By typing your name below, you acknowledge that you are e-signing this form for your student.
Your answer
Do you have another student needing an Opt-In form?
*
Yes
No
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