Get CA PVSD School Counseling Informed Consent 2020-2024

K12. ca.us Nicole Schackelman Counselor nschackelman pvsd. k12. ca.us Child s Name Grade Teacher I am the legal parent/guardian of. I encourage you to contact me whenever you have questions or concerns. Tara Matheson Counselor tmatheson pvsd. Parents/guardians or school staff may refer students for counseling or students may request counseling. I have read understand and agree to the terms of the attached School Counseling Informed Consent. Please check one I give permission for my child to receive school counseling services at Pleasant Valley School District for the 2015-2016 school years. For counseling that extends beyond two sessions in a school year or that is planned on a regular basis parent/guardian permission is to be obtained. The bottom portion of this consent form may be returned to your child s school. I understand that school counseling services are short-term services aimed at the more effective education and socialization of my child within the school community. The counselor will make the child aware in an age appropriate manner of these limits to confidentiality and will inform the child when sharing information with others. Because these services are provided to minor children in the school setting I understand that the school counselor may share information with parents/guardians the child s teacher and/or administrators or school personnel who work with the child on a need to know basis so that we may better assist the child as a team. The counselor is also required by law to share information with parents or others in the event the child is in danger of harm to self or others. SCHOOL COUNSELING INFORMED CONSENT PLEASANT VALLEY SCHOOL DISTRICT Pleasant Valley School District offers short-term individual counseling to students. I understand that these services are not intended as a substitute for diagnosis or treatment for any mental health disorder. I acknowledge that it is my responsibility to determine whether additional or different services are necessary and whether to seek them for my child. In order to build trust with the child the school counselor will keep information confidential with some possible exceptions. counseling services. I choose to decline school counseling services for my child at this time. I understand that I may request Phone Daytime phone Date E-mail. I understand that these services are not intended as a substitute for diagnosis or treatment for any mental health disorder. I acknowledge that it is my responsibility to determine whether additional or different services are necessary and whether to seek them for my child. I acknowledge that it is my responsibility to determine whether additional or different services are necessary and whether to seek them for my child. In order to build trust with the child the school counselor will keep information confidential with some possible exceptions. I understand that these services are not intended as a substitute for diagnosis or treatment for any mental health disorder. I acknowledge that it is my responsibility to determine whether additional or different services are necessary and whether to seek them for my child. In order to build trust with the child the school counselor will keep information confidential with some possible exceptions.