Your child has been referred for follow up counseling. Either your child requested it, a member of our staff referred your child to our counselor, or you have asked for support. In order to provide such support, we need parent permission. Please review the terms of telecounseling below:

1. I understand that “telecounseling” includes video conferencing, emails and telephone conversations

2. Unless I explicitly provide agreement otherwise, telecounseling exchanges are strictly confidential. Any information my child chooses to share with my counselor will be held in the strictest confidence. My private information will not be released unless the counselor has reasonable suspicion that someone is about to physically harm someone else, harm themselves, or if there is an abuse of children, the elderly, or the disabled.

3. I understand that I have the right to withdraw or withhold consent from telecounseling services at any time. I also have the right to terminate counseling at any time.

4. While telecounseling will be conducted primarily through private videoconferencing, I understand that there are always some risks with telecounseling services including, but not limited to, the possibility that the transmission of your information could be intercepted by unauthorized persons.

5. I will work with my counselor to identify an alternative communication method (most often phone) in the event that the videoconferencing tool fails.

6. I understand that my child may benefit from telecounseling but that results cannot be guaranteed or assured.

7. I understand and accept that telecounseling does not provide emergency services. If my child is experiencing an emergency, I understand that the protocol would be to call 911 or proceed to the nearest hospital emergency room for help. If my child is having suicidal thoughts or making plans to harm myself, I may also call the National Suicide Prevention Lifeline at 1- 800-273-TALK (8255) for free 24-hour hotline support.

8. I will be responsible for the following: (1) providing the computer and/or necessary telecommunications equipment and internet access (2) arranging a location is confidential for my child’s or my (adolescent) telecounseling sessions.

9. I agree not to record telecounseling sessions.

10. I understand that if the counselor is concerned about my child or we lose contact, or if my child fails to show for a scheduled videoconference, the counselor will contact me by phone to check on our well-being.

If you want our counselor to provide telecounseling with your child, please digitally sign the form below.

If you have any questions concerning the counseling program, please contact the School Counselor.