INFORMED CONSENT FOR SCHOOL COUNSELING SERVICES
The ASE Academy — intern-resources.html
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[School Name] | School Counseling Program
Counselor: _________________________  Date: ________________

IMPORTANT: Review with your district's legal counsel before use.
Adapt to your state's confidentiality statutes and district policy.

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ABOUT THE SCHOOL COUNSELING PROGRAM

The school counseling program at [School Name] provides individual counseling,
small-group counseling, and classroom-based social-emotional learning.

Our approach is grounded in Advocating Student-within-Environment (ASE) theory —
we attend to both the student's individual strengths and the environmental conditions
(school, home, community) that shape their development.

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SERVICES

Individual Counseling:
Short-term (typically 4–8 sessions), 30–50 minutes, held during the school day.
Focus: academic, social-emotional, or personal concerns.

Group Counseling:
Small groups of 4–8 students. Topics: academic skills, friendship, coping with change.
Meets weekly for 6–10 sessions.

Classroom Guidance:
School-wide lessons on academic success, social skills, and personal development.

Consultation:
The counselor may consult with teachers, administrators, or other staff to support
your child's success. Consultation does not require sharing confidential content.

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CONFIDENTIALITY

What is private:
What your child shares in counseling sessions is kept confidential. We do not
routinely share session content with teachers, administrators, or parents/guardians.

Exceptions — when confidentiality may be broken:
  1. SAFETY: If your child discloses risk of harm to self or others, I am legally
     and ethically required to take action.
  2. ABUSE OR NEGLECT: If your child discloses abuse or neglect, I am legally
     required to report to child protective services.
  3. LEGAL REQUIREMENT: If required by court order.
  4. PERMISSION: If you or your child give written permission.

FERPA Notice:
Your child's counseling records are part of their educational record. Parents/
guardians of students under 18 have the right to inspect these records under FERPA.

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YOUR RIGHTS

As a parent or guardian, you have the right to:
  • Be informed about the nature and purpose of counseling services
  • Ask questions about the counseling approach and goals
  • Withdraw consent for counseling at any time
  • Request information about your child's progress
  • Be notified if your child is in a safety situation

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CONSENT

I have read and understood the above information. I consent to my child
participating in school counseling services at [School Name].

Student Name (print): ________________________  Grade: _______  DOB: ___________
Parent/Guardian Name: _____________________________________
Relationship to Student: __________________________________
Signature: _______________________________  Date: ___________

Preferred contact for counselor: [ ] Phone  [ ] Email  [ ] Note home
Contact information: _______________________________________________

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COUNSELOR

I have explained the nature of counseling services to the parent/guardian
and answered their questions.

Counselor Signature: _____________________  Date: ___________

[Keep in the student's confidential counseling file]

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