Informed+Consent-Group+F

Consent-Group F Tracy Rowland, Misty Cochran, Sandy Harris, Kami Bennett, Megan Kennedy, Jodie Webb, Vernestine Payne, Katie Hodge

**INFORMED CONSENT FORM ** **Springboro High School ** **Springboro, OH **  _ Child’s Name Counselor’s Name

Introduction: As part of our mission to provide an excellent education for our students, Springboro High School has a counseling staff dedicated to helping students achieve academic and personal success. Every student has equal access to and is assigned to a specific counselor, who cares deeply about them. Students may ask to see their counselor themselves, or be referred by a teacher or parent.

About the Counselors: Our counselors each hold an M.Ed. in School Counseling from an accredited university. Many also have extra classes, skills and experience in the fields of education and counseling, as well as many other areas.

About the Counseling Process: Among the services our counseling department offers are initial evaluation, short term one-on-one counseling, crisis help, group counseling, and referrals if needed. We do not provide long-term counseling, psychiatric care, or psychological evaluation. Participation in school processing is voluntary. The counselors do not accept gifts for helping students, unless they are handmade presents.

Benefits/Risks: Meeting with the counseling department is optional. Working with our counselors may provide lots of benefits such as improved social or school skills, but sometimes these changes are hard.

Privacy and Limits: Talks between counselors and students are private, with a few possible exceptions. These exceptions include: the counselor suspects abuse of a child or elderly person, the counselor thinks the security of the school is at risk, the counselor thinks the student might commit suicide or kill or hurt someone else, or if a judge forces the counselor to turn her records in to the court. All records from sessions are kept locked up and safe.

Right to File Access: <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">Parents have the right to access their child(ren)’s written, filed school records.

<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">Contact: <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">Parents can contact the counselors by calling the office at (937)555-5555, between 7:30 AM and 4:00 PM.

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<span style="color: #000000; font-family: 'Times New Roman','serif';">Print Student Name:
 * <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">Please return this page to your child’s homeroom teacher. Keep the first page for your records. **

<span style="color: #000000; font-family: 'Times New Roman','serif';"> I have read and understand the above, and I give permission for my child to receive counseling services at Springboro High School for the 2011-2012 school year. <span style="color: #000000; font-family: 'Times New Roman','serif';">I understand that I may withdraw my consent at any time by signing and dating a written note requesting termination of counseling services. <span style="color: #000000; font-family: 'Times New Roman','serif';"> I have read and understand the above, and I choose to decline school counseling services for my child at this time. <span style="color: #000000; font-family: 'Times New Roman','serif';">I understand that I may request counseling services at a later date if desired. <span style="color: #000000; font-family: 'Times New Roman','serif';">Student: <span style="color: #000000; font-family: 'Times New Roman','serif';">Parent/Guardian <span style="color: #000000; font-family: 'Times New Roman','serif';">Principal
 * //<span style="color: #000000; font-family: 'Times New Roman','serif';">Please check one: //**
 * //<span style="color: #000000; font-family: 'Times New Roman','serif';">Please sign and date: //**