Informed Consent for School Counseling & Group Counseling

I would like for my student to participate in individual and/or group

counseling at (insert school name) with counselor, Mr. Williams. Individual
counseling provides students with the opportunity to explore feelings, thoughts,
and behaviors in a private, one-on-one setting with a licensed school counselor.
Group counseling gives students the experience of working with two or more
students under the guidance of the counselor in order to address feelings, thoughts,
behaviors, and/or to learn specific skills. The purpose of both individual and group
counseling is to work on academic, personal, social, and emotional issues so
students will be prepared to focus on school achievement.
Counseling is voluntary and without a guarantee. You or your child may
stop counseling at any time without any negative consequences. At times, sensitive
or difficult topics are addressed which may bring about emotional discomfort.
However, dealing with these issues can lead to better understanding and
acceptance of self and others.
Confidentiality will be guarded within legal and ethical limits of the
counseling profession. Sometimes other counseling professionals may need to be
consulted but the students identity will be protected. If your child shares that he or
she is being harmed, may be harmed, plans harm to himself/herself, another person
or property, the counselor will share the information with parents or other
appropriate persons. In group counseling, the counselor will make every effort to
ensure confidentiality, but cannot guarantee group member compliance.
I have read and discussed the above statements with my child. We both
understand the conditions in which my child will be participating in counseling
with Mr. Williams (insert school name).
______________________________________ _____________
Parent Signature Todays Date

______________________________________ _____________
E-mail Address Daytime Phone #

______________________________________ _____________
Students Name Teacher/Grade




Permission to Participate in Group Counseling Services

Name of Student________________________________Date_______________

Your child has been referred by his/her teacher and/or voluntarily submitted the
appropriate paperwork to participate in a (insert group name here) group. This
group will last for (number of sessions) sessions, meet for (time) minutes per
session and will help your child learn about:

Expressing personal feelings and gaining awareness of changing (or changed)
family dynamics in a safe, accepting environment
Gaining strength and normalizing experiences through others in the group
Providing a group environment to problem solve and cope with emotions
Increasing student self-esteem and developing peer-to-peer interactions
To be a support systems for students, parents, and school staff with students
who are experiencing or have experienced parental divorce/separation
Increasing communication between students, parents, and school

I do give my permission for my child to participate in this group.

Signature of parent or guardian______________________________________

Date: ___________________________


I do not give my permission for my child to participate in this group.

Signature of parent or guardian_______________________________________

Date: ___________________________

If you have any questions, please call Mr. Williams, your professional school
counselors.