Virtual School Counseling Request Form

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Hello and thank you for your interest in virtual sessions with your school counselor. When parents request a series of counseling sessions we request informed consent by the parent, which in this form. Because virtual sessions are unique, we ask parents to be present as well. I am including the ethical standards provided by the American School Counselor Association below.

Email *

Student's Name (One form per student) *

Parent's Name *

How would you like Mr. Ortiz to contact you? *

Microsoft Teams

ZOOM

Phone

Parent's Contact Information (Phone, Email, or any type of contact. *

Please check each box if you have read and understood the following Ethical Standards for Virtual/Distance Counseling provided by the School Counselor. * *

Adhere to the same ethical guidelines in a virtual/distance setting as school counselors in face-to-face settings

Recognize and acknowledge the challenges and limitations of virtual/distance school counseling

Implement procedures for students to follow in both emergency and non-emergency situations when the school counselor is not available

Recognize and mitigate the limitation of virtual/distance school counseling confidentiality, which may include unintended viewers or recipients

Inform both the student and parent/guardian of the benefits and limitations of virtual/distance counseling

Educate students on how to participate in the electronic school counseling relationship to minimize and prevent potential misunderstandings that could occur due to lack of verbal cues and inability to read body language or other visual cues that provide contextual meaning to the school counseling process and school counseling relationship

Required

I give my consent for my child to participate in virtual counseling sessions. *

Yes

A copy of your responses will be emailed to the address you provided.

Submit

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