26-27 El Rincon COUNSELING CONSENT Form

Dear Parent /Guardian,                                     

My name is La’Keisha Jerome, and I am the school counselor at El Rincon Elementary School. My goal is to help all of our students succeed in their academic success, college and career readiness, and social-emotional development. To do this I often work with students individually or in small groups. These sessions are designed to help students with academic progress, emotional recognition and regulation, social-emotional learning, classroom behaviors, problem-solving skills, decision-making, and social interactions. These sessions will equip students with strategies to succeed in and out of the classroom. 

Your child has been invited to participate in weekly or bi-weekly individual and/or small group counseling sessions. Referrals are based on school data, staff consultation, and self-referrals. I will work together with your child’s teacher to set up a schedule once you have approved your child’s participation. 

Because of this method of communication I am not able to check the appropriate box, but on the hard copy of this document, you would be able to identify who this school-based counseling referral was made ◻by the student’s teacher. ◻by school staff.  ◻by the school counselor.  ◻by the parent(s)/legal guardian(s).   ◻after reviewing school data.  ◻by the student (self-referral).

School-based counseling services:  

  • Are short-term, solution-focused, school-based counseling (1-8 sessions) individual and/or group sessions. 

  • Are not intended as a substitute for medication, psychological counseling, or diagnosis, which are not the responsibility of the school. 

  • Require parent/guardian written permission if counseling extends beyond two sessions in a school year.

Because school-based counseling is based on a trusting relationship between counselor and counselee, the school counselor will keep information confidential with some possible exceptions. Exceptions to confidentiality include legal mandates to report any abuse, neglect, or situations in which a child may present a physical danger to self or others. The school counselor may share information with parents/guardians, the child’s teacher, and/or administrators who work with the child on a need-to-know basis, so that we may better support the child as a team. 

If you have any questions about the individual or group sessions, please do not  hesitate to contact me by phone at (310) 842-4340, or by email at lakeishajerome@ccusd.org.


Sincerely,

La’Keisha Jerome, MSEd, MA, PPS 

School Counselor

Email *
Student's Name (First and Last) *
Student's Teacher *
Do you agree that you are the student's legal guardian and have read, understand, and agree to the terms of this School Counseling Informed Consent?
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Review the information below, then CHOOSE ONE.

In granting permission for my child to participate in individual and/or group counseling services, I acknowledge that:

- Should my child be invited to take part in a regular group, I will be provided with further details at that time.

- I have the right to withdraw my consent at any moment by signing and dating a written request to discontinue counseling services.

In declining permission for my child to participate in individual and/or group counseling services, I acknowledge that:

- I can ask for counseling services in the future if necessary.

- I am declining an intervention suggested based on data or staff advice.

By typing your name below, you agree that you are the student's legal guardian, and you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application. 
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