Informed Consent for a Student (Under 18)
TO BE COMPLETED BY PARENT/GUARDIAN/CAREGIVER for students under the age of 18.
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Email *
School Student Attends *
Student's Grade Level *
Introduction: Counseling Partners of Los Angeles (CPLA) offers a comprehensive school-based counseling program and support services, providing the tools, support and oversight essential to ensure the greatest opportunity for every student to grow toward their full potential emotionally, intellectually, morally and socially. CPLA strives to have students, parents, teachers, and counselors actively involved in nurturing student’s success and wellbeing by providing an exceptional level of support, expertise and oversight. CPLA is committed to success for every student every day. There is no additional cost for counseling services as it is one of the programs offered by your school. The counselors see students that are referred by faculty, parents, and the students themselves. You can refer your child for any academic, social, or emotional concerns you may have by calling the school and asking to speak with the CPLA counselor. *
Required
Background/Notification of Supervision: CPLA counselors have a passion for helping children and adolescents and are very excited to work with your school. CPLA counselors are graduate level or post-graduate level students obtaining their Master’s Degree in Counseling or Doctoral Degree in Counseling. On a weekly basis, the counselors meet with a licensed clinician for supervision and training. The counselor works under the license of this licensed clinician. *
Required
Provision of Services: It is the policy of CPLA to obtain parent/guardian/caregiver written permission for counseling that extends beyond one session in a school year or that is planned on a regular basis. Services include intake assessment, short-term individual counseling, crisis intervention, group counseling, and outside referrals as needed. I understand that school counseling services are aimed at the more effective education and socialization of my child within the school community. I understand that these services are not intended as a substitute for psychological counseling, diagnosis, or medication, which are not the responsibility of the CPLA counselors. I acknowledge that it is my responsibility to determine whether additional or different services are necessary and whether to seek them for my child. *
Required
Benefits/Risks: I understand that there may be both risks and benefits associated with participation in counseling. Counseling may improve my child’s ability to relate to others, provide a clearer understanding of himself/herself, along with values, goals, and an ability to deal with everyday stress. I understand that counseling may also lead to unanticipated feelings and change, which might have an unexpected impact on my child and his/her relationships. *
Required
Confidentiality: I understand that the CPLA counselor will keep information confidential, with some possible exceptions. The counselor is a mandated reporter and is required by law to share information with parents or others in certain circumstances: Presenting a serious danger to self or another person. Evidence or disclosure of suspected abuse (physically or sexually) or suspected neglect (Department of Children and Family Services would be contacted). Threats to school security. The counselor will make the child aware of these limits to confidentiality. *
Required
Records: Records are retained by CPLA and do not become a part of a student’s school file. Records are stored safely with attention to privacy. *
Required
Telehealth: CPLA will be providing Telehealth services in order to meet the needs of our partner school communities. Telehealth is a collection of means or methods for enhancing health care, public health, and health education delivery and support using telecommunications technologies. Telehealth encompasses a broad variety of technologies and tactics to deliver virtual medical, health, and education services. Telehealth is not a specific service, but a collection of means to enhance care and education delivery. I understand that Telehealth based services and care may not be as complete as face-to-face services. I also understand that if the student's counselor believes they would be better served by another form of intervention (e.g. face-to-face services), they will be referred to a mental health professional who can provide such services in their local area. I understand that the student has a right to confidentiality with Telehealth under the same laws that protect confidentiality during in-school, in-person CPLA counseling. I further understand that there are risks unique and specific to Telehealth, including but not limited to, the possibility that the therapy session or other communication by the student's CPLA counselor to others regarding their treatment could be disrupted or distorted by technical failures or could be interrupted or could be accessed by unauthorized persons. I understand that I can withdraw my consent to Telehealth communications by providing written notification. *
Required
Complaints: Counseling Partners of Los Angeles receives and responds to complaints regarding the practice of psychotherapy by any unlicensed or unregistered counselor providing services at any school contracted through CPLA. To file a complaint, contact CPLA Executive Director and Co-Founder, Therese Funk, through any of the following ways: (310) 459-CPLA (2752), or therese@counselingpartnersofla.org, or www.counselingpartnersofla.org, or 2016 West Washington Blvd. Los Angeles, CA 90018. *
Required
Consent for Counseling: My ELECTRONIC SIGNATURE below indicates that I have read and understand this document and I give permission for my child to receive counseling services if referred. I also understand that this consent shall remain valid for the remainder of the time this student is enrolled at the school. I am free to refuse or withdraw consent at any time through writing. Note: This is not a referral for counseling. PLEASE TYPE YOUR NAME BELOW. *
YOUR relationship to Student? (Ex: Mother, Father, Grandmother, etc...). *
YOUR Phone Number: *
YOUR Email Address: *
STUDENT'S name: *
STUDENT'S phone number: *
STUDENT'S email address: *
What is today's date? *
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A copy of your responses will be emailed to the address you provided.
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