Notice and Consent for School Counseling Services
Student's Name
*
First Name
Last Name
Select Campus
*
Please Select
Elementary School
Intermediate School
Middle School
High School
Grade Level
*
Please Select
Pre-Kindergarten
Kindergarten
1st
2nd
Grade Level
*
Please Select
3rd
4th
5th
Grade Level
*
Please Select
6th
7th
8th
Grade Level
*
Please Select
9th
10th
11th
12th
Parent / Guardian Name
*
First Name
Last Name
I give written permission for my child, identified above, to receive mental health-related services as described in this form:
*
Yes, I consent to the District providing all routine mental-health related services.
No, I do not consent to the District providing any routine mental health-related services.
Signature
*
Submit
Should be Empty: