FormsParents & StudentsHealth → Consent for Individual Counseling

Consent for Individual Counseling

About this Form

Form number: 339-1

Audience:  Parents/Guardians

Last revised: November 2015

The school psychologist can provide counseling to students with permission from the parent or guardian. Many students improve their school performance and attitude towards school by taking part in counseling sessions. These sessions are not intended to replace the need for non-school based counseling services. Information disclosed by the student during counseling sessions is not typically revealed to anyone else, except under certain circumstances (for example, evidence that a student is a threat to themself, others, or property).

Please sign and have the student return this consent form. This consent for counseling is valid for one school year. Student participation in counseling is strictly voluntary and parent consent to provide counseling to the student may be withdrawn at any time. Parents/guardians are encouraged to contact the school psychologist to keep informed about their student’s progress.

For group counseling, see MCPS Form 339-2, Consent for Group Counseling

Adobe PDF Consent for Individual Counseling32 KEnglish
Adobe PDF Consentimiento para Consejería Individual25 KSpanish
Adobe PDF Formulaire de Consentement Pour Thérapie Individuelle25 KFrench
Adobe PDF Ưng Thuận cho Tư Vấn Cá Nhân25 KVietnamese
Adobe PDF 個人輔導同意書116 KChinese
Adobe PDF 개별 카운슬링 동의서40 KKorean
Adobe PDF የግል/ለግሰብ የምክር አገልግሎት የስምምነት መግለጫ51 KAmharic

Forms require Adobe Acrobat Reader 8 or higher. Get Acrobat