Parent/Guardian Consent/Referral Form
We are pleased to announce that Discovery Elementary School is offering students voluntary counseling support on campus. Your child has been referred for this service in order to help him/her reduce barriers and achieve greater academic success. Please read the information regarding services below and sign for consent.

I grant permission for my minor child to participate in the individual/group counseling support provided by School Social Worker, Yelena (Leena) Smithson, PPSC, LCSW #93953, the School Counselor, Tina Benedict, MA, PPS and/or Bachelor of Social Work (BSW), and/or Master of Social Work (MSW) Interns under the supervision of Leena Smithson. Interns are current students in undergraduate (BSW)/graduate (MSW) level courses and are accruing internship hours with San Marcos Unified School District (SMUSD) as per an agreement with their respective graduate schools.  I understand that services can be provided by interns and/or SMUSD School Social Workers.  In the even that one of these listed providers are unavailable, I consent to having the School Psychologist, Mindy Young, provide these services to my child. 

I understand that school-based counseling support entails weekly structured groups and/or individual counseling sessions: weekly, biweekly, monthly, or student led check-ins depending on the student’s needs. Services may include phone or e-mail contact and referrals to additional resources.  School-based counseling services will only be offered in accordance with the academic calendar (i.e. services will not occur during scheduled school breaks). In order to promote my child’s successful completion of this program, I will make myself available for any feedback necessary and/or participate in sessions if requested/needed and scheduling permitted. Services will be terminated after brief intervention (typically 4-8 individual and 6-10 group sessions) with the exception of crisis situations. If further services are needed I will seek additional mental health services outside of the school-setting.    

If circumstances change and the school model reverts back to virtual learning, the school social worker team will reach out regarding obtaining additional consent for virtual social-emotional services.

Please note that referring a student for school-based services does not automatically enroll them in school-based services. Short-term School-Based Counseling will be available based on severity of need and current availability. Long-term and consistent counseling or therapeutic services for more intensive needs should be obtained outside of the school district and can be access through your insurance provider or by contacting 211 for community mental health services. 

If you or someone you know needs immediate support now or is experiencing a mental health crisis, call or text 988 or chat
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Email *
Student's First Name: *
Student's Last Name: *
Please READ AND CHECK ALL of the following information about potential risks and expectations when utilizing school-based support services *
My child is insured through Medi-Cal *
If my child is or may become eligible for public benefits (Medi-Cal): I authorize the LE/district to release student information for the limited purpose of billing Medi-Cal/Medicaid and to access Medi-Cal health insurance benefits for applicable services. 
Student's Teacher: *
Student's Grade: *
Assistance Needed (Check all that apply): *
Resources: referrals or resources to community resources. Student Check-In: Child is in need of a check-in for social/emotional support. Consultation: Consultation - need some suggestions or help with child's behaviors, emotional state, or other concern at home.
Level of Need (at time of Referral) *
Has your student experienced any of the following family changes (please check all that apply)? *
Reason for Referral (please check at least 1 box) *
Brief Description of Concern/Need: *
In what ways do you notice your concerns are creating a barrier for your child academically, socially, or behaviorally in the school setting? *
Best number to reach you at *
Availability (Please leave some options for days/times that you would be available to talk further) *
Please note that office hours are typically 8:15-3:45.
Parent/Guardian Name. Please note that this will be considered your electronic signature for consent of services. *
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