Notice and Consent for School Counseling Services

Notice and Consent for School Counseling Services
Student's Name*

First NameLast Name
Select Campus*
Grade Level*
Grade Level*
Grade Level*
Grade Level*
Parent / Guardian Name*

First NameLast 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*

Clear
Should be Empty: