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Grundy County school counseling program
Posted On:
Thursday, July 16, 2020

Grundy County School Counseling Program Parent Consent Form

Student                                                                                           Date


I give permission for my son/daughter to participate in these counseling sevices (check all that apply)

Weekly Individual CounselingIndividual Counseling As Needed

Group Counseling (when available)Bi-monthly Individual Counseling

Counseling services are confidential. The relationship between a student and his or her counselor carries communication privileges and rights to confidentiality. Any information shared by your son or daughter will be kept confidential. There are times when students divulge information that I feel should be shared with parents. I will encourage them to do so or request permission to discuss the mater with a parent or guardian myself. I will do this anytime I feel it is in the best interest of your son or daughter. There are also several situations in which I am required by law to share details of a counseling session with the appropriate authorities. These situations include:

A.    If a counselee reports neglect, physical or sexual abuse of a child or someone who cannot otherwise protect themselves.

B.     If an individual threatens to harm themselves or others

C.     If my records are subpoenaed by the courts for purposes of litigation.

D.    If you grant me permission to release records to another professional.

As legal guardian of(student), with an understanding of the conditions above, I give permission for him or her to participate in counseling services in the Grundy County School System.


Parent/Guardian Signature

Please list below any areas of concerns or goals for counseling that would be beneficial for your child to address in counseling.







Please note that in the case that too many students want counseling services, students will be put on a waiting list based on severity of need.

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