ASD School Counseling Services Parent/Guardian Consent
Dear Parent/Guardian(s):

Alpine School District provides counseling services and/or behavioral consultations for students in need with our licensed social workers, school counselors and school psychologists. These services are provided as needed during school hours and may include: individual counseling, small groups, individual skills development,
behavior management, and administration/teacher consultations.

During the course of our sessions, students may discuss their personal views and experiences. Information
disclosed in these sessions are confidential unless not disclosing such information would be harmful to the
student or others. Please note that school counseling interventions are provided to help your child succeed in the school setting. Service providers have a responsibility to ensure that an appropriate administrator is informed of any information that concerns potential problems or at-risk situations that might occur. Information concerning life-threatening situations will be shared with the parent and appropriate school personnel. Information gathered from an interview or counseling session may be shared with the administrator or other school personnel only on a need-to-know basis. State law requires that information suggestive of child abuse must be reported to the appropriate governmental agency.

Under the Utah Code Ann. §53A-13-301 and §53A-13-302 of the Utah Family Education and Privacy Act, school
district personnel are required to have your consent as parent or legal guardian if information is sought from your
child concerning the following issues:
a. political affiliations or political philosophies (except as provided under Utah Code §53A-13-101-1
or rules of the State Board of Education);
b. mental or psychological problems;
c. sexual behavior, orientation, or attitudes;
d. illegal, anti-social, self-incriminating, or demeaning behavior;
e. critical appraisals of individuals with whom the student or family member has close family relationships;
f. religious affiliations or beliefs;
g. legally recognized privileges and analogous relationships, such as those with lawyers, medical
personnel, or ministers;
h. income, except as required by law..
Please understand that under the law, your student cannot participate in the counseling discussions unless and
until the signed letter of permission is returned. Complete this form and return it to the school as soon as possible.

If you are interested in having your student receive these services, a signed permission is required. Please complete this form as soon as possible. If you have any questions, feel free to contact the service provider Monday through Friday by email or calling the school.

This is available as a short-term service (4-6 visits). If further help is needed, appropriate referrals will be made.
ATTENTION: Due to Alpine's "Return to Learn" plan during the pandemic, meetings with a school counselor, school psychologist, or social worker are being offered in person or online. To facilitate online student's needs we can provide either online or by telephone meetings. To protect your student and counselor one of the following scenarios must be in place during these counseling meetings. 1. One counselor, the student, and a parent are present. 2. One counselor and more than one student are present. 3. Two counselors and one student are present. 4. The counselor can record the meeting via google hangouts *
Student's Name *
Parent/Guardian Digital Signature *
By typing in your name below you are giving permission for your student to meet with the school counselor individually or in a group setting. You can discontinue service at any time by contacting the counselor.
Parent/Guardian Phone Number *
Parent/Guardian Email Address *
The Utah Family Education Rights and Privacy Act requires a two-week waiting period prior to the student receiving services unless a parent waives this notification period. *
* OPTIONAL - Please describe any concerns you have about your child or reasons you would like your child to receive services:
Under the Utah Code §53A-13-301 and §53A-13-302 of the Utah Family Education Rights and Privacy Act (FERPA), school district personnel are required to gain the consent of the parent or legal guardian before meeting with a student, except in response to a situation which a school employee reasonably believes to be an emergency or as authorized under Title 62A, Chapter 4A, Part 4, Child Abuse or Neglect Reporting Act, or by order of a court. *
Required
Submit
Never submit passwords through Google Forms.
This form was created inside of Alpine School District. Report Abuse