Glocester Public Schools ~
West Glocester Elementary School ~
111 Reynolds Road Chepachet, RI 02814
I [Parent/Guardian of WGES Student] give permission for my child [WGES Student] to receive in-school counseling support with their school service team member, Danielle Anderson, School Social Worker. These services include, but are not limited to, developing and achieving Social and Emotional Learning (SEL) goals, managing behavioral or executive functioning challenges, and other related services designed to address student supports needed in order for the student to access their academic work and to be successful in the school setting. Services may take place individually, in a small group, or within the classroom setting.
I [Parent/Guardian of WGES Student] understand the following with respect to in school service sessions:
1) I understand that this consent form is good for the duration of time that my child is at West Glocester Elementary School.
2) I understand that I have the right to withdraw consent at any time without affecting my child’s right to future services or supplementary support to which my child would otherwise be entitled.
3) I understand that in order to build trust with the child, the school social worker will keep information confidential with
some possible exceptions.
4) I understand that the school social worker may share information with: the
child’s parents/guardians, the child’s teacher, and/or administrators or school personnel who
work with the child on a need to know basis, so that we may better assist the child as a team.
5) I understand that school-based counseling services are short-term services intended to support the education of my child within the school community.
PLEASE NOTE: The school social worker is required by law to share information with parents or others in certain circumstances: i.e. Student reports harm to self or reports knowledge of danger or harm to others, evidence or disclosure of abuse (physically or sexually) or neglect, and /or threats to school security.
Please direct all questions and communications related to these services to Mrs. Anderson at danderson@glocschools.org or 401-567-0350
