Supplementary

Consent Information for Parent/Guardians

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Who am I and why have I given you this form?
My name is Molly Hayes and I am a Masters of Counselling
student from the University of Lethbridge. I am honoured
to be a part of your familys experience with the Calgary
Catholic School District (CCSD) counselling services and I look
forward to the opportunity to help you meet your counselling
goals. With your permission, I have the chance to work with your
child this school year. You may have already consented to the
involvement of Instructional Services for extra psychological and learning
help but the purpose of this form is to give you more information about what counselling with
me could look like so that you can make an informed decision about working with me.

What does counselling with me look like?
I am dedicated to ensuring that every child I work with has a safe place to explore
his/her goals for change. I see great value in talking with parents/guardians and warmly
encourage students to talk to the adults in their lives about what is going on for them and what
they are learning in counselling. Therefore, I also encourage you to speak with me about your
thoughts and concerns regarding your child and to seek general updates on the counselling
process.1 I believe that it is important to support young people so that they grow into the best
versions of themselves. To provide your child with the best opportunities for personal success, I
will introduce various interventions to them and give them a space to talk about it, but I wont
force them to try anything that they are too uncomfortable with.

How I intend to protect and support your child
I am in my final year of the Masters of Counselling program and I completing my
counselling practicum with CCSD this school year. All of my work is supervised by a very
experienced CCSD psychologist named Wes Bartel. I have listed my contact information as well
as Wes at the end of this document; you are welcome to contact either of us regarding the
counselling process. I am supervised to ensure that your child gets the best treatment possible
with CCSD. I have attached an additional document that provides more specific information
about supervision for you to review.


1
I borrowed some of the information and/or wording of this section, with permission, from a consent form

originally written by Erika Kewley and Dawn McBride (2012; Last update was by McBride on August 28, 2014 with
the help of Bethany Mills)

Supplementary Consent Information for Parent/Guardians

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Like the psychology professionals at CCSD and my university that supervise and teach me, I too
adhere to the Canadian Psychologists Code of Ethics. Protecting a clients privacy to these
ethical standards is extremely important to me. What this means is that I will not talk to anyone
about your childs issues, including family-related ones that they may share with me unless they
give me permission to do so; this includes teachers or principals within the school district. I
promise to tell you if I have serious concerns about your childs safety. 1

To track progress, I keep brief session notes. Although you have the right to see these
notes, this can feel like a violation for youth. For this reason, I ask that you tell me before I work
with your child if you would like to see my notes; this way I can inform them that what I write
down in our sessions will be seen by you. Digital copies of my notes are stored in password-
protected documents within the districts network. Paper copies of my notes are stored in a
locked filing cabinet in a locked office.

Some benefits and risks of seeking counselling 1
Trying out some new techniques and talking about their experiences might make your
child feel like they have more control over their environment. Counselling might also improve
your childs interactions with others at home and school and might make them feel happier.
However, as a part of the growth process, sometimes unexpected and uncomfortable feelings
may surface for your child. I am trained and able to handle these reactions. As your child learns
new ways of managing their experiences, they might also try out new ways of behaving. If you
want ideas on how to help your child through this transition, please ask me.

Giving permission
You and your child have rights. It is your right to give permission for your child to seek
counselling help and it is my responsibility to give you as much information as you need
in order to make an educated decision about it. I also believe that it is important for your child
to be given as much information as possible in a developmentally appropriate manner so that
they understand what to expect, the benefits and risks of the process, and how they are
supported and protected. For this reason, a child and youth friendly informed consent
document (like this one) has been created and attached for your review. I welcome you to take
your time and to ask questions about counselling and consent.

You can contact me at molly.hayes@cssd.ab.ca or 403 500 2002 or my supervisor, Wes Bartel at
wes.bartel@cssd.ab.ca or 403 500 2619

1 I borrowed some of the information and/or wording of this section, with permission, from a consent form

originally written by Erika Kewley and Dawn McBride (2012; Last update was by McBride on August 28, 2014 with
the help of Bethany Mills)

Supplementary Consent Information for Parent/Guardians

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Consent for Counselling

My signature below signifies that I understand the information in this consent form and that I
am being asked to give my permission for my child to seek extra help through counselling.
The following documents mentioned in this consent form must
be given to you for review:
Have you been given these
CCSD permission form for Instructional Services involvement
documents to read?
Supplementary Consent Information for Parents/Guardians

(thats this document!)
University of Lethbridge consent form for supervision and
YES or NO
recording
Child and youth friendly consent document for counselling

You deserve the chance to ask questions about the counselling

process and about giving consent.

Have your questions been

answered to your
satisfaction?

YES or NO

I give permission for my child ___________________________________________ to be

involved in counselling with Molly Hayes.


______________________________
Parent/Guardian Name (print)


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Parent/Guardian Name (print)


______________________________
Parent/Guardian Name (print)


______________________________
Parent/Guardian Name (print)

_____________________________
Parent/Guardian Signature


_____________________________
Parent/Guardian Signature


_____________________________
Parent/Guardian Signature


_____________________________
Parent/Guardian Signature

Graduate Student Counsellor signifying that consent has been obtained:

______________________________________________________________

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Date


_______________
Date


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Date


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Date

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Date