School Counseling Informed Consent

School Counseling Informed Consent Form

Eagle County Charter Academy

1105 Miller Ranch Road, Edwards CO (970) 926-0656

Introduction

The Eagle County Charter Academy is committed to providing quality education to its students. In an effort to achieve this goal, parents/guardians or school staff may refer students for counseling, or students may request counseling. The focus of the counseling program is to help students better understand the world they live in and make better decisions that help them live functional lives. There is no cost for counseling services provided at Eagle County Charter Academy.

Background

Eagle County Charter Academy’s counselor is Mrs. Alicia Pribramsky, who has Master’s Degree in School Counseling, is certified by the Colorado Department of Education as a School Counselor, and is a National Certified Counselor (NCC). Mrs. Pribramsky has been employed by Eagle County Schools for eighteen years and has taught Spanish to grades k-4 and 7-8 at Eagle County Charter Academy for fifteen of those years. She completed her internship at Battle Mountain High School and Eagle County Charter Academy during the 2012-13 school year.

Provisions of Services

It is the policy of Eagle County Charter Academy to obtain parent/guardian written permission for individual counseling that extends beyond two sessions in a school year or that is planned on a regular basis. Services include intake assessment, short-term individual counseling, crisis intervention, group counseling, and referrals as needed.

I understand that school counseling services are aimed at the more effective education and socialization of my child within the school community. I understand that these services are not intended as a substitute for psychological counseling, diagnosis, or medication, which are not the responsibility of the school. I acknowledge that it is my responsibility to determine whether additional or different services are necessary and whether to seek them for my child.

Benefits/Risks

I understand that there may be both risks and benefits associated with participation in counseling. Counseling may improve my child’s ability to relate with others, provide a clearer understanding of himself/herself, along with values, goals, and an ability to deal with everyday stress. I understand that counseling may also lead to unanticipated feelings and change, which might have an unexpected impact on my child and his/her relationships.

Confidentiality

In order to build trust with the child, the school counselor will keep information confidential with some possible exceptions. I understand that the 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 required by law to share information with parents or others in certain circumstances:

• Presenting a serious danger to self or another person

• Evidence or disclosure of abuse (physically or sexually) or neglect

• Threats to school security

• Criminal or delinquency proceedings are pending

The counselor will make the child aware of these limits of confidentiality and will inform the child when sharing information with others. If you would like the counselor to share information with a third party, such as a community counselor, psychiatrist, social services worker, or pediatrician, you will need to sign an additional release of information form.

Contact

I understand that I am entitled to ask questions and receive information about methods or techniques used by the counselor and the length of counseling. I am free to seek a second opinion or end counseling at any time.

Child’s Name

I, , am the legal parent/guardian of .

I have read, understand, and agree to the terms of the School Counseling Informed Consent.

Please check one:

I give permission for my child to receive individual and/or group counseling services while attending Eagle County Charter Academy.

(If your child is invited to join a recurring group, you will receive additional information at that time.)

I understand that I may withdraw my consent at any time by signing and dating a written note requesting termination of counseling services.

I choose to decline school counseling services for my child at this time.

I understand that I may request counseling services at a later date if needed.

Phone: Daytime phone Cell phone

Email