School Counseling Parent Request Form

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This form is intended to provide you with important information about the counseling relationship and your child’s rights and responsibilities. Sessions may be provided either face-to-face and/or virtually. This form provided consent for either method.

Provision of services: Individual and group counseling sessions are voluntary, available to all students, are intended to be brief (6 or less sessions) in nature, and aim to promote the effective educational, career, social, and emotional development of the student to support school success, with a focus on the Great 8 Skills for Daily Life. The counselor will continue to support the student by working with the family to obtain a referral to community services, as needed.

Confidentiality is a key feature of the counseling experience: The information discussed during counseling will not be shared with anyone except for those required by law or when permission is granted by the student. The situations required by law are listed below:

*In the case that the school counselor feels as though your child is in danger of hurting himself/herself and/or others, the school counselor is required to take action. Every effort will be made to work with you and inform you in such a case.
*In instances of current or previous emotional abuse, physical abuse, sexual abuse, and/or neglect of a minor or elder are shared, school counselors are required to take action.
*In instances where illegal activity is reported to the school counselor, the school counselor is required to take action.

Please Note: Although the information shared during counseling is confidential, because the child is a minor, parents/guardians have a right to be informed of their child’s general progress.

Student's First and Last Name (One form per student) *

Parent's First and Last Name *

How would you like the counselor to contact you? *

Phone

Parent's Contact Information *

Check the behavior(s) that generally describe what the student is struggling with: *

Conflict Resolution: This can be with a teacher or a peer.

Healthy Thinking: struggles with negative thinking and self-talk

Self Management: struggles with self control and emotional outburts

Relationship Skills: struggles maintaining positive connections, cooperating with others, showing respect for others their space, and their belongings

Goal Oriented Skills: struggles initiating or completing tasks, listening carefully or critically

Decision Making: struggles with problem solving, accepting responsibility, reflecting on better choices for next time

Personal Responsibility: struggles taking ownership, being honest

Self Awareness: struggles desiring to improve, expressing feelings, knowing strengths/weaknesses

Social Awareness: struggles interacting positively with others, respecting personal space and/or ideas and perspectives of others

Grief Counseling

Outside Mental Health Support (i.e therapy, psychiatry, assessments, etc.)

Other:

What would you like to talk to the counselor about? *

Please check each box if you have read and understand the following Ethical Standards for Counseling Services provided by the School Counselor. *

School Counselors adhere to the same ethical guidelines in face-to-face and virtual settings.

Recognize and acknowledge the challenges and limitations of virtual 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 confidentiality, including unintended viewers or recipients during a virtual counseling session

Inform both the student and parent/guardian of the benefits and limitations of face-to-face and virtual counseling

Educate students on how to participate in the virtual 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 school counseling services. I understand that these sessions may take place virtually and/or face-to-face. *

Yes

Please type your full name that you are voluntarily consenting for your child to take part in school counseling services and you understand that you may revoke these services at any time. *

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