Permission Form for Individual Counseling

Dear Parent/Guardian,
Your child has been invited to participate in individual counseling. He/She has been informed
and would like to participate in counseling. They will be exploring their ideas, attitudes, feelings,
and behaviors about the selected topic of your student's choice.

We will meet once per week for between twenty to thirty minutes each times. It would be
scheduled so that your student will miss as little class as possible. I feel that your child would
benefit from participating in these sessions. He/She needs your permission to participate in
counseling. Please sign the permission form and return to school with your student.

Confidentiality:

The process of counseling is dependent upon trust between the counselor and the child. One of
the most powerful ways to build trust is for the counselor to maintain confidentiality of what is
discussed during the counseling session. To this end, Miss Allen will keep what is discussed
between her and your child confidential EXCEPT for the following cases:

1. There is clear and imminent danger to your child or others (i.e. self-harm, thoughts of
suicide, thoughts of hurting others).
2. The information relates to mental, physical, and emotional abuse.
3. A court orders the release of the information.
4. The information relates to criminal activity.

Thank you,

Kendra Allen
Counselor

I (parent/guardian). _________________________, give my child____________________,

permission to participate in individual counseling sessions.

Parent/Guardian signiture____________________________________ Date_______________