Consent Forms
Counseling Services Consent Form
Click here to access Informed Consent
Text of consent form (for translation purposes). To complete the actual consent form, click on the link above, print/sign, and return to the counselor (emailing a picture of the signed page will be fine).
Antioch Unified School District is committed to providing quality education to its students. In an effort to achieve this goal, parents/guardians or school staff may refer students to be screed for counseling, or students may request counseling. School counseling is considered a regular educational service and therefore students may be seen without parent consent. However, as a good faith practice the counselor will not see students in an ongoing manner or group setting without first receiving parent permission. In addition, school counselors are not able to provide long-term intensive mental health therapy services to students. The school counselor would be happy to provide information about community resources if you feel your student is in need of additional support. As a parent/guardian you have the right to decline certain educational services such as school counseling. If you do not want your child to be seen individually or in a group setting, please contact the school Principal and provide a written statement or decline services below on this form. Please read the form carefully. Feel free to contact the counselor with any questions you may have.
“The School Counseling Credential authorizes the holder to: 1) develop, plan, implement and evaluate a school counseling and guidance program that includes academic, career, personal and social development; 2) advocate for the high academic achievement and social development of all students; 3) provide school-wide prevention and intervention strategies and counseling services; 4 ) provide consultation, training and staff development to teachers and parents regarding students' needs; and 5) supervise a district-approved advisory program as described in Education Code Section 49600"
Provisions of Services
It is the policy of Orchard Park School to obtain parent/guardian written permission for individual counseling that extends beyond periodical check-in meetings or that is planned on a regular basis. Services include short-term individual counseling, crisis intervention, group counseling, and community referrals as needed. Counseling services take place during regular school hours and will be provided by the school counselor and/or the school counselor intern free of charge. Students will work on academic, social, emotional, and behavioral goals as they relate to school. For approximately 6-8 weeks, students practice and review our school rules, friendship skills, problem solving skills, mindfulness and more in a supportive environment. It is understood that school counseling services are aimed at helping students within their educational journey as part of our school community. It is understood that these services are not intended as a substitute for psychological counseling, diagnosis, or medication.
Confidentiality
In order to build trust with the child, the school counselor will keep information confidential with some possible exceptions. The counselor may share information with parents/guardians, the child’s teacher, administrators or school personnel who work with the child on a need to know basis, so that we may better assist the child as a team.
The counselor is required by law to share information in the following circumstances:
School counselor feels that your child is in danger of harming him/herself or others. Every effort will be made to work with you and inform you first in such a case.
Instances of previously unreported sexual or physical abuse of a minor or elder are brought to light; California state law requires the school counselor to report this information to the proper authorities.
Threats to school security.
In the case counseling records are court ordered by subpoena, the school counselor will attempt to contact you first. However, he/she must comply with the court.
The counselor will make the child aware of these limits of confidentiality and will inform the child when sharing information with others.
Limits to Confidentiality (during distance learning)
It is understood that there are risks and consequences from virtual school counseling that are beyond the control of the school counselor.
Although the internet provides the appearance of anonymity and privacy in counseling, privacy is more of an issue online than in person. Texting, e-mail, phone calls and videoconferencing aren’t fully secure modes of communication. Please understand the potential risks of confidentiality being breached through your personal unencrypted email, lack of password protection or leaving information on a public access computer. Other potential risks of breaching confidentiality could include messages failing to be received if they are sent to the wrong email address. Confidentiality could be breached in transit by an unauthorized person, internet service providers or by others with access to the guardian’s or student’s account/ computer. Students/ Guardians accessing the internet from public locations or shared locations with the home should consider the visibility of their screen to people around them.
The counselor has a right to his or her privacy; meetings with the counselor may not be recorded without the prior express permission of the counselor. Furthermore, the counselor restricts the use of any copies or recordings the client makes of their communications. It is strictly prohibited to post edited or unedited meetings, images of the counselor or any communication from the counselor on the internet.
If you would like the counselor to share information with a third party, such as a community counselor, psychiatrist, social services worker, or pediatrician, you will need to sign an additional release of information form.
Discontinuation of Services
Students and parents have the right to discontinue counseling at any time without any legal or moral obligations. The counselor has the right to discontinue counseling with students under the following conditions:
When it is determined counseling is no longer beneficial to the student
When it is determined that another professional might be able to better serve the student
When the student refuses to cooperate with the proposed counseling treatment plan
If any of these situations apply, the counselor will inform the student directly, and contact parents/guardians to inform them of the decision.