Signature
My signature below indicates my consent to all of the matters above as they relate to the student. Under certain serious conditions, in order to meet the medical and/or safety needs of the student or of the community, this consent allows discussing pertinent information with parents/legal guardians, and/or, faculty/staff employees of the school.
I also understand that this consent shall remain valid for the remainder of the time the student is enrolled in this school. I am free to refuse or withdraw consent at any time through writing.
Note: This is a Consent to counseling, NOT a Referral for counseling.
**Fill out a separate consent form for each of your children.
(Electronic signatures will constitute legal signatures of consent.)
Your signature authorizes Counseling Partners of Los Angeles to review your child’s grades to assist the counselor in supporting academic progress and to utilize this data for the purpose of research and accountability studies.
PLEASE TYPE YOUR FULL NAME BELOW: