Student Session Form

STUDENT SESSION FORM

Student Information

Date of Birth:    Student ID:    Grade / Program:

Parent / Guardian Information (if applicable)

Relationship:    Phone:    Email:

Session Details

Proposed Session Date:    Time:    Duration:

Tutoring    Counseling / Advising    Assessment    Enrichment / Skills Practice    Group Session    Virtual (online)

Invoice    Card on File    Cash    Check

Attendance, Cancellation & No-Show Policy

Sessions are scheduled by mutual agreement. Cancellations require at least 24 hours' notice unless otherwise stated in an agreed plan. Late cancellations or no-shows may be charged up to the full session fee. Repeated missed sessions may result in termination of scheduled services. I acknowledge and accept these terms:

I acknowledge the Attendance, Cancellation & No-Show Policy and understand potential fees and scheduling consequences.

Confidentiality, Records, and Mandatory Reporting

Provider will maintain written or electronic session notes. These records are confidential and will not be released without written authorization except as required by law. Exceptions to confidentiality include: suspected child abuse or neglect, credible threats of harm to self or others, and other disclosures required by statute. By checking the box below, you acknowledge understanding of these limits:

I acknowledge the confidentiality terms and exceptions described above.

Recording and Media Consent

Sessions will not be recorded, photographed, or otherwise reproduced except with explicit advance written consent. If consent is granted, media will be used only for instructional, training, or progress documentation as described below. Please indicate consent preferences:

Consent to audio recording for educational/progress purposes    Consent to video recording for educational/progress purposes    Consent to still photographs for progress documentation

Medical, Allergies, and Emergency Information

Emergency Contact Name:    Relationship:

Phone:

Learning Supports, Accommodations & Goals

IEP    504 Plan    Private Tutoring    Other (describe below)

Progress Reporting and Release of Information

Provider may share summary progress reports with the student's school or designated representatives only with written authorization, except as required by law. Please indicate whether you authorize routine progress communications:

I authorize sharing routine progress summaries with the student's school or designated school personnel.

Acknowledgment and Authorization

By signing below, I certify that I am the student (if age 18 or older) or the parent/legal guardian authorized to consent for the student named above. I attest that the information provided on this form is accurate to the best of my knowledge. I authorize the provider to deliver the services described, to maintain records as required, and to communicate with designated school personnel or other authorized representatives as specified. I understand the policies concerning cancellations, fees, confidentiality limits, and media use and agree to comply with them.

I further release the provider from liability for accidental injury occurring during scheduled sessions, except for injuries resulting from willful misconduct or gross negligence by the provider. This authorization remains effective until revoked in writing by the signer, except to the extent that action has already been taken in reliance on it.

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