Informed Consent

____________ High School

Ohio School District

Child’s Name: ____________________________________________________

Teacher’s Name: __________________________________________________

I would like my child to participate in the ______________________ group at_____________

High School. I have read the information attached and have had the opportunity to discuss the
small group counseling concerns for my child with the school counselor.

o I give my consent for my child______________________________ to participate in

small group counseling at _______________ High School. I understand that my child’s
participation is voluntary and confidential.

o I don’t give my consent for my child__________________________ to participate in

small group counseling at ____________________ High School.

Parents/ Guardian Signature: _____________________________________________________

Home Phone: ________________________ Mobile Phone: _____________________________
Email: ________________________________________________________________________
Counselor Signature: ______________________________Date_________________________
Student Signature: ________________________________Date_________________________

Comments, Questions, or Concerns:

Thank you,
Miss Stewart
High School Counselor