Purpose of the Counseling Services Consent Form
This form is used to obtain consent for a student to receive counseling services through the school’s counseling program. It outlines the nature of the services provided, the rights and responsibilities of both the student and their parents/guardians, and ensures that parents/guardians understand the confidentiality and purpose of the counseling sessions. This form must be completed and signed by the parent or legal guardian for a student to access counseling services.
Parent/Guardian Consent:
By signing this form, I, the undersigned parent or guardian of the named student, acknowledge and agree to the following:
- Consent for Counseling Services
I grant permission for my child to participate in counseling services provided by the school. I understand that these services may include individual or group sessions aimed at supporting my child's emotional, social, and academic needs.
- Understanding of Confidentiality
I understand that counseling sessions are confidential and that the counselor will not disclose information shared during sessions without my child's permission, except in cases where disclosure is required by law, such as concerns of harm to self or others, or as required by mandatory reporting laws.
- Right to Withdraw
I understand that I have the right to withdraw my consent for my child's participation in counseling services at any time by providing written notice to the school. If consent is withdrawn, counseling services will be discontinued.
- School’s Role
I understand that the school’s counseling services are designed to provide short-term support and that referrals to outside mental health providers may be recommended if long-term or specialized care is needed.
- Release of Liability
I release the school, its counselors, employees, and representatives from any liability or claims related to my child’s participation in the counseling services, provided they have acted in good faith and with professional care.
- Automatic Denial in Absence of Form
I understand that if this form is not completed and signed, my child will not be able to participate in the school’s counseling services.
- Questions and Clarifications
Any questions or concerns regarding the school’s counseling services can be directed to the School Counseling Office at:
Address
Email
Phone Number
