Mental Health Decline / Withhold Consent for Services Form

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This form, in compliance with HB 1557, may be used to decline or withhold consent for a student from school based mental health services. School based mental health services include individual counseling, group counseling, and ongoing mentoring. Below, you may choose to decline/ withhold consent for one or all of these services for the current school year.

NOTE:
*This does not exempt students from behavioral health crisis services, which may include emergency intervention and/or assessment deemed necessary by a school based mental health staff member to maintain the health and safety of students and others (SB 7026).
*This does not exempt students from Character Education Standards Instruction (Rule 6A-1.09401)

Email *

Date *

YYYY

Student Name (Last Name, First Name) *

School *

Grade *

Parent/Guardian Name (Last Name, First Name) *

Relationship to Child *

School-based mental health service(s) that I am opting out of for my child (please choose all that apply): *

Individual Counseling

Group Counseling

Ongoing Mentoring

Required

Thank you

This information will be submitted to the Coordinator of Psychological Services and the Coordinator of Social Work and Mental Health Services. It will then be disseminated to School Based Mental Health Staff Members at the student's school.

Send me a copy of my responses.

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