Raymond W. Kershaw Counseling Permission Form-2024/2025 
Please help us get to know your child and your concerns by completing this form. This information will help us better understand how we can support your child. This information will be kept confidential.

*Once the form is received, counseling services will begin within two weeks and last approximately 6-8 weeks, contingent on student progress.   

Megan Corcoran, School Counselor, M.ED
mcorcoran@mtephraimschools.com 
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Student's First & Last Name
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Today's date *
MM
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DD
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YYYY
Parent/Guardian Name and Relationship to Child
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Parent/Guardian Email address *
Parent/Guardian Phone Number
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Student's Teacher
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Parent/Guardian signature to grant permission for counseling services during the 2024/2025 school year.*
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Please let us know if there are any separation, divorce, or custody arrangements. 
Type N/A if not applicable.

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List all people (including ages and relationship to the child) currently living in the household.
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Please let us know if there is any additional household information you would like to share.
Please identify your primary concern(s)- Academic (Check all that apply)
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Required
Please identify your primary concern(s) - Personal/Social (Check all that apply)
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Required
Please identify your primary concern(s)- Emotional (Check all that apply)
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Required
Describe your student's relationships with classmates/peers.
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Describe any difficulties in school (i.e. subjects, times of day, locations)
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Describe what your child likes to do for fun, special interests, hobbies, etc.
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Please provide any other information you would like your counselor to know.
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What are some goals you hope to see your child achieve through counseling?
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