Opt-In For Ongoing Therapeutic Counseling/Mental Health Services

I hereby give my permission for my child to participate in the following ongoing therapeutic counseling/mental health services provided by a school counselor, therapist, or school-based mental health practitioner:  Check the box below for each therapeutic/counseling/mental health service you want to be available to your child. Ongoing School-Based Mental Health Counseling or Therapy  Ongoing Large-Group/Small-Group Therapeutic Counseling or Mentoring Activities Formal Assessments/Surveys (related to social behaviors, feelings, etc.) Crisis Intervention (Please note that permission is not required when immediate intervention is needed to safeguard the health and safety of the student or others.) You may rescind permission for a student to participate in ongoing therapeutic counseling/mental health services at any time by providing written notice to the school counselor.

_______________________________ Student’s Full Name (Printed)         Date: _____________ 
 

_______________________________  Parent/Guardian Name (Printed)      Date: _____________ 
 

_______________________________  Parent/Guardian Name (Signature)   Date: _____________