Consent Form for School Counseling Services
(Custodial Parent/Legal Guardian
I am the custodial parent/legal guardian of
(My Child)
Your answer
and I hereby give my consent for My Child to receive counseling services through
The School
Your answer
My Child is not married, is not a member of the United States Armed Foces, and has not received a Declaration of Emancipation from any Court of Law.
I understand that counseling services offered through the School are primarily short-term, temporary services aimed at the more effective education and socialization of My Child within the School community, and to provide the means for teachers and the School Administration to serve My Child and the School community more effectively. These services may involve the individual participation of My Child, or the participation of My Child in conjunction with family, teacher(s) and/or the School Administration. I understand that these services are not intended as a substitute for emergency psychological intervention, nor do they take the place of permanent, long-term or comprehensive psychological counseling, therapy or medication, which are not the responsibility of the School. I acknowledge that it is my sole responsibility to determine whether additional or different services are necessary, and whether to seek them for My Child.
I have the right to withdraw this consent by written notice to the School *
Required
Parent/Guardian's Name
Your answer
Date
MM
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YYYY
Relationship to Child
Your answer
Authorization of Disclosure
Because these School Counseling Services are primarily intended to serve My Child as a member of the School Community, in addition to circumstances otherwise allowed or required by law, I authorize the School counselor, in his or her discretion, to share any information, diagnosis or recommendation derived from these services, and only such information, with me or another parent or legal guardian of My Child, My Child's teacher(s), the School Principal or other School Administrators. Such information of my child will be used only for the purposes of facilitating the education or socialization of My Child in the School community.
This authorization shall remain valid only until
MM
/
DD
/
YYYY
I have the right to withdraw this consent by written notice to the School *
I understand that I have the right to receive a true copy of this authorization. I acknowledge that a true copy of this authorization has been received by me.
Required
Parent/Guardian's Name
Your answer
Date
MM
/
DD
/
YYYY
Relationship to Child
Your answer
Please Keep a Copy of This Consent Form For Your Records
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