Eastern Local School District CONSENT FOR

COUNSELING SERVICES
1170 Tile Mill Rd., Beaver, Ohio 45661
740.226.6402

STUDENT NAME_______________________________ BIRTH DATE ___________________

TEACHER NAME ________________________DATE:________GRADE ______ Room #______

COUNSELOR/ SOCIAL WORKER _____________________________________or MSW INTERN

A counseling program is offered in the Eastern Local School District to supplement the schools academic program.
Individuals and small groups work on activities constructed to improve and/or develop self-esteem, self-confidence,
self-awareness and personal responsibility. The emphasis in the counseling program is on the positive and especially
the encouragement of the students individual worth, who he/she is, and what he/she is capable of doing. The
objective of the counseling program is to promote growth in social, emotional and academic areas.

I understand that pre-licensed graduate counseling interns or School Counselors may provide counseling services in
schools. In all cases, a licensed and/or credentialed School Counselor supervises the intern counselors.

I understand that the effectiveness of counseling services and my childs progress may be monitored by testing tools
such as Achenbach, pre-post tests and Piers Harris Self Concept Scale.

____yes, I consent to tests ____no, I do not. Please initial______.

I further recognize and understand that all information disclosed within sessions is confidential and may not be
revealed to anyone outside the counseling staff of the Eastern Local School District without written consent from
myself, except when disclosure is required by law (i.e., when there is reasonable suspicion of abuse of children or
elderly persons, and when the client presents a serious danger of harm or violence to him or herself or another.)

I understand that at times it may be in my childs best interest for the counselor to disclose some information to the
class teacher, school psychologist nurse or principal. In such circumstances I give my permission for the counselor to
release info to school personnel.

____yes, I do consent ____no, I do not consent. Please initial_____.

Thank you,

Mr. Matt Hines

School Principal

____ Yes, I DO consent to counseling services at school

____ No, I DO NOT consent to counseling services at school.

__________________________________________ ___________________________________

Signature of Student Date

__________________________________________ ____________________________________

Signature of Parent/Guardian Date

Print Name of Parent/Guardian_____________________________ Daytime Phone #__________________

Relationship to Child_______________________________________ Legal Custody ___Yes ___ No