Parent Consent Form (English)

Alliance Leadership Middle Academy

              

             CONSENT FOR COUNSELING SERVICES

STUDENT NAME:______________________________   BIRTH DATE:____________________

TEACHER NAME: ________________________DATE:________GRADE::_______

COUNSELOR: Mrs. Ross

 A counseling program is offered at Alliance Leadership Middle Academy to supplement the school’s academic program.  Individuals and small groups work on activities constructed to improve and/or develop self-esteem, self-confidence, self-awareness and personal responsibility.  The emphasis in the counseling program is on the positive and especially the encouragement of the student’s individual worth, who he/she is, and what he/she is capable of doing.  The objective of the counseling program is to promote growth in social, emotional and academic areas.

I understand that all information disclosed within sessions is confidential and may not be revealed to anyone outside the counseling staff of Alliance Leadership Middle Academy without written consent from myself, except when disclosure is required by law (i.e., when there is reasonable suspicion of abuse of children or elderly persons, and when the client presents a serious danger of harm or violence to him or herself or another.)

I understand that at times it may be in my child’s best interest for the counselor to disclose some information to the class teacher, school psychologist or principal. In such circumstances I give my permission for the counselor to release info to school personnel.

____yes, I do consent ____no, I do not consent. Please initial_____.

Thank you,

Kelly Ross

School Counselor

____          Yes, I DO consent to counseling services at school

____          No, I DO NOT consent to counseling services at school.

                                          

Signature of Student_________________________________                                           Date_________________________

Signature of Parent/Guardian___________________________

Print Name of Parent/Guardian_____________________________                  Daytime Phone #__________________

Relationship to Child_______________________________________  Legal Custody: ___Yes   ___ No