Student Session Forms

STUDENT SESSION FORMS

Student Information

Student Name:

Date of Birth:   Student ID:

Parent / Guardian Information (if student is a minor)

Emergency & Medical Information

Session Details

Type of Session: Academic Tutoring Counseling Specialized Instruction

Preferred Days/Times:

Session Start Date:   Estimated Number of Sessions:

Consent for Services and Evaluation

By signing this form, the signer hereby authorizes and consents to provision of educational and/or therapeutic services provided by authorized staff. Services may include assessment, individualized instruction, progress monitoring, behavioral supports, and consultations as appropriate. The signer acknowledges that participation is voluntary and may be discontinued by providing written notice.

I consent to the student receiving the services described above.

Recording & Media Consent

Educational sessions may occasionally be audio- or video-recorded for assessment or instruction purposes. Recordings will be stored securely and used only for educational or supervisory reasons unless additional written permission is obtained.

I authorize audio/video recording as described above.

Transportation & Field Trip Authorization (limited)

For off-site educational activities directly related to the student's instructional plan, the signer authorizes the student to be transported by authorized school personnel or approved vendor. Separate notices will be provided for each event.

I authorize transportation for applicable educational activities.

Release of Records & Communication

The signer authorizes release of educational/medical information necessary for service coordination to those professionals directly involved in the student's program or in accordance with lawful requests. This authorization is valid for the duration of the services or until revoked in writing. Revocation will not affect disclosures already made relying on this authorization.

I authorize release of records as necessary for service coordination.

Billing, Fees, and Insurance

The signer acknowledges responsibility for all fees not covered by insurance or institutional funding. Payment is due according to agreed schedule. Late payments may incur interest or administrative charges. Cancellation or no-show fees will apply as stated below.

Per session Monthly installment Upfront payment

Cancellation and No-Show Policy

Sessions cancelled less than 24 hours before the scheduled time, or missed without prior notice, may incur a cancellation fee equal to the full session fee unless otherwise agreed in writing. Repeated cancellations or no-shows may result in suspension of services.

I acknowledge and accept the cancellation and no-show policy.

Confidentiality & Mandatory Reporting

Records and communications are maintained in accordance with applicable confidentiality rules. Exceptions exist for disclosures required by law, including but not limited to obligations to report suspected abuse or harm to self or others, court-ordered disclosures, or instances where the student provides written consent for release of information.

Additional Notes / Behavioral Considerations

Acknowledgment and Certification

I certify that the information provided in this form is true and complete to the best of my knowledge. I understand the nature of the services to be provided, the policies regarding payment and cancellations, and the limits of confidentiality as described above. I authorize the entities identified to provide services and to exchange information as necessary for the student’s educational program and safety.

Relationship of signer to student:

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