PARENT PERMISSION FOR SERVICE PROVIDERS-Ridgeline Elementary 2023-2024 
Dear Parent/Guardian(s):

Alpine School District provides counseling services, therapy, and/or behavioral consultations for students in need with our licensed social workers, school counselors, and school psychologists. These services are provided as needed during school hours and may include: individual counseling, therapy, small groups, individual skills development, behavior management, classroom observations, data gathering, and administration/teacher consultations. This is available as a short-term service and if further help is needed, appropriate referrals can be made. 

During the course of our sessions, students may discuss their personal views and experiences. Information disclosed in these sessions are confidential unless not disclosing such information would be harmful to the student or others. Please note that service provider interventions are provided to help your child succeed in the school setting. 

Service providers have a responsibility to ensure that an appropriate administrator is informed of any information that concerns potential problems or at-risk situations that might occur. Information concerning life-threatening situations will be shared with the parent and appropriate school personnel. Information gathered from an interview or counseling session may be shared with the administrator or other school personnel only on a need-to-know basis. State law requires that information suggestive of child abuse must be reported to the appropriate governmental agency.

Topics of discussion may include but are not limited to:
  • Emotional Regulation (i.e. anxiety, stress, relaxation)
  • Life Events (i.e. grief, loss, graduation, divorce)
  • Bullying Resilience
  • Self-Esteem 
  • Social Skills (i.e. friends, respect, conflict resolution, problem solving)
  • Behavior Management (i.e. impulse control, self regulation)
According to the Utah Family Education and Privacy Act, school district personnel are required to have your consent as a parent or legal guardian before meeting with a student if information is sought from your child. (see Utah Code Ann. §53E-09-203)

NOTE: Parental consent is not required in response to a situation in which a school employee reasonably believes to be an emergency, or as authorized under Utah Code §80-02-602 (Utah Child Abuse or Neglect Reporting Act) or by order from a court. State law requires that information suggestive of child abuse must be reported to the appropriate governmental agency.
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The Utah Family Education Rights and Privacy Act requires a two-week waiting period prior to the student receiving services unless a parent waives this notification period.
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Student's Name *
Parent/Guardian Digital Signature *
By typing in your name below, you are giving permission for your child to meet with a service provider accepting the above conditions. Permission is valid for the current school year. You can discontinue service at any time by contacting the school or service provider. 
Parent/Guardian Phone Number *
Parent/Guardian Email Address
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OPTIONAL - Please describe any concerns you have about your child or reasons you would like your child to receive services:
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