STUDENT ASSENT FORM — SCHOOL COUNSELING SERVICES
The ASE Academy — intern-resources.html
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[School Name] School Counseling Program

Note: While parental consent is legally sufficient for school counseling,
student assent — genuine, informed agreement — is an ethical requirement in
ASE practice. Adapt language to developmental level.

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VERSION A: GRADES K–5 (read aloud with student)

Hi! My name is _________________, and I am the school counselor.

My job is to talk with students when things feel hard — at school, at home,
or with friends. Our conversations are private, which means I won't tell
your teacher what you shared with me. (There are a couple of exceptions —
I'll always explain those when we meet.)

You don't have to talk to me if you don't want to. And if you start
coming to talk with me and later decide you don't want to, that's okay.

Do you want to try meeting with me?

  [ ] Yes, I'd like to try.
  [ ] I'm not sure — I want to think about it.
  [ ] No, not right now.

Student Name (print): _____________________  Grade: _____
Student Signature: ________________________  Date: _______

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VERSION B: GRADES 6–12

The school counselor is not here to fix you.

Your parent or guardian has given permission for you to meet with me.
Before we begin, I want to make sure you understand what that means.

What counseling is:
A conversation — about whatever is making school or life hard right now.
I am here to think with you, not to fix you or report back to your teachers.

Privacy:
What you share in our sessions is private. I won't share it with your
teachers, administrators, or parents — with three important exceptions:
  (1) If I believe you might hurt yourself or someone else, I'll need to act
      to keep you safe.
  (2) If you tell me someone is hurting or neglecting you, I'm required by
      law to report it.
  (3) If a court requires me to share information.
I will always tell you if I need to do one of these things.

Your choice:
You are not required to participate. If you choose not to, that will not
affect your standing at school. If you start meeting with me and later want
to stop, just tell me.

Questions before we proceed:



Do you agree to participate in school counseling?

  [ ] Yes — I understand what counseling is and I agree to participate.
  [ ] I'd like to try one session and then decide.
  [ ] No — I don't want to participate at this time.

Student Name (print): _____________________  Grade: _____  Age: _____
Student Signature: ________________________  Date: ___________

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COUNSELOR NOTE

If the student declines assent, document and honor that decision. Do not
coerce participation. Note in the file whether you will re-approach.

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