Parent Consent - North Park School District / Olson Family Counseling, P.C.

Between Olson Family Counseling, P.C. ("OFC") and the parent/guardian of the student named below, in coordination with North Park School District

This form is a consent agreement between Olson Family Counseling, P.C. ("OFC") and the parent/guardian of the student named below. It asks for permission for the student to participate in school-based, non-clinical social emotional, executive functioning, and behavioral support services delivered by OFC in coordination with North Park School District ("District"). OFC and the District have a separate written agreement governing how OFC provides these services on school grounds and works with District staff; the District is not a party to this parent consent form and is not required to sign it. These services are primarily delivered virtually (by video, and when necessary audio-only) and may also be delivered in person at the school when scheduling, programming, or student needs make in-person support appropriate. Whether delivered virtually or in person, these services are educational school supports — they are not psychotherapy, medical care, behavioral health treatment, or emergency/crisis services.

Parent consent form—school-based non-clinical support services.

Page 1

Parent Consent — North Park School District / Olson Family Counseling, P.C.

The District has contracted with OFC under a separate written agreement to provide additional school-based social emotional, executive functioning, and behavioral support services that would otherwise be performed by school support staff. FERPA permits schools to disclose education-record information to contractors, consultants, volunteers, and other third parties under the "school official" exception when the provider performs an institutional service the school would otherwise use employees for, is under the school's direct control for use and maintenance of education records, uses personally identifiable information only for the authorized purpose, follows redisclosure limits, and meets the District's criteria for a school official with a legitimate educational interest¹. The OFC-District agreement is separate from this parent consent form. Service delivery format. These services are primarily virtual, meaning the OFC support staff member typically meets with the student remotely by secure video (or audio-only when necessary) while the student is at school or, with District and parent approval, in another approved location. Services may also be delivered in person at the school when scheduling, program design, or student needs make in-person support appropriate. The mode of delivery does not change the non-clinical, educational nature of the services. These services are designed to support school functioning by helping students build practical skills in areas such as:

• Emotional regulation and coping skills in the school setting.
• Social skills, communication, and peer interaction.
• Executive functioning, organization, focus, task completion, and school routines.
• Behavior support strategies aligned with the educational environment.
• Problem-solving, conflict-resolution, and age-appropriate self-advocacy skills.
• Connection to school staff, family supports, and outside resources when appropriate.

I understand that the services provided under this consent are:

• Non-clinical, educational, and school-based support services, delivered primarily virtually and sometimes in person.

Parent consent form—school-based non-clinical support services.

Page 2

Parent Consent - North Park School District / Olson Family Counseling, P.C.

• Not psychotherapy, counseling, medical care, psychiatric care, psychological testing, or behavioral health treatment.
• Not a diagnosis, clinical assessment, treatment plan, or substitute for therapy, medical care, crisis services, or emergency services.
• Not intended to create a therapist-client, physician-patient, or clinical treatment relationship between OFC and the student or family.
• Not billed to insurance or Medicaid by OFC as clinical behavioral health treatment under this school support agreement unless a separate written clinical intake, informed consent, and authorization process is completed.

Services may include (virtually or in person):

• Tier 2 small-group skill-building and support.
• Tier 3 individualized non-clinical support.
• Social emotional learning activities.
• Brief school-based check-ins.
• Classroom, group, or individual skill practice.
• Behavioral observation and consultation with school staff.
• Support with school-based routines, transitions, peer conflict, and coping strategies.
• Parent/guardian communication related to school-based support when appropriate.

If the student appears to need psychotherapy, diagnosis, risk assessment, crisis evaluation, psychological testing, medication evaluation, substance-use treatment, medical treatment, or another clinical service, I understand that the District and/or OFC may recommend that the parent/guardian seek separate clinical services. Any clinical services by OFC would require a separate intake process, separate clinical consent, separate privacy notices, and separate determination of fit and availability.

Participation is voluntary unless the support is otherwise required or addressed through a legally applicable school process, such as an IEP, 504 Plan, behavior plan, disciplinary process, safety plan, or other District obligation. I may request to withdraw my child from these non-clinical OFC support services at any time by contacting the school or OFC in writing or by email.

Withdrawal from OFC support services does not automatically change, waive, or terminate any District obligation, IEP service, 504 accommodation, safety response, disciplinary process, truancy process, or other school requirement. If the student has an IEP or 504 Plan, changes to required special education, related services, accommodations, or placement must be handled through the applicable District process.

Services may be provided by trained professionals and supervised staff from OFC, which may include licensed professionals, pre-licensed clinicians, paraprofessional support staff, graduate interns, and supervised interns. Staff will provide only services within the role assigned by the District and OFC and under appropriate supervision. Whether the support occurs virtually or in person, the role and scope remain the same.

I understand that:

Parent consent form—school-based non-clinical support services.

Page 3

Parent Consent – North Park School District / Olson Family Counseling, P.C.

• OFC staff may consult with District staff and OFC supervisors to coordinate support and promote student safety and school success.
• OFC staff providing services under this agreement are not acting as the student's private therapist unless a separate clinical relationship has been established in writing.
• OFC may change the assigned support person based on staffing, scheduling, supervision, program needs, or student needs.

I understand that OFC does not make final District decisions about special education eligibility, IEP services, 504 eligibility, 504 accommodations, discipline, placement, grade promotion, attendance, transportation, or other educational rights or obligations. IDEA is the federal law that ensures a free appropriate public education ("FAPE") and special education and related services for eligible children with disabilities, and Colorado implements special education requirements through the Exceptional Children's Educational Act ("ECEA") rules².
Section 504 is a federal civil rights law that prohibits disability discrimination by recipients of federal funding, including school districts, and the District remains responsible for Section 504 implementation³. OFC support services are intended to supplement school supports and do not replace the District's responsibilities under IDEA, ECEA, Section 504, the ADA, or other applicable laws.
If my child has or may have a disability, I understand:

• OFC may provide observations, general support information, or participation information to the District support team when appropriate and allowed by law.
• OFC does not determine whether my child qualifies for an IEP or 504 Plan.
• OFC does not unilaterally change my child's IEP, 504 Plan, placement, school day, or required services.
• If I have concerns about disability-related rights, services, accommodations, evaluations, discipline, restraint/seclusion, shortened school day, or placement, I should contact the District's special education director, 504/ADA coordinator, school administrator, or other District-designated contact.

I understand that records created or maintained by the District or by OFC acting for the District in connection with these school-based services are expected to be education records governed by the Family Educational Rights and Privacy Act ("FERPA"), not HIPAA, unless a separate clinical relationship or other legal arrangement applies. FERPA protects education records that are directly related to a student and maintained by an educational agency or institution or by a party acting for that agency or institution⁴.
The U.S. Department of Education and U.S. Department of Health and Human Services have issued joint guidance addressing how FERPA and HIPAA apply to student health and education records maintained about students⁵. Because these services are school-based, non-clinical supports provided on behalf of the District, parent requests to inspect, review, amend, or obtain copies of related education records should be directed to the District according to District FERPA procedures.

Parent consent form—school-based non-clinical support services.

Page 4

Parent Consent - North Park School District / Olson Family Counseling, P.C.

I authorize the District and OFC to share information reasonably necessary to plan, provide, supervise, coordinate, document, evaluate, and improve my child's participation in these school-based support services.

Records or information that may be shared include:

• Student name, grade, school, schedule, attendance information, and relevant school contact information.
• Referral reason and school-based support needs.
• Relevant educational, behavioral, social emotional, executive functioning, attendance, safety, and discipline information.
• Relevant IEP, 504 Plan, behavior plan, safety plan, health plan, or other school support plan information.
• Behavioral observations and participation information.
• General progress updates and support strategies used at school.
• Parent/guardian contact information and communication preferences.
• Information needed for supervision, staffing, scheduling, service coordination, and safety.

Parties or classes of parties who may share or receive information include:

• District administrators, teachers, school support staff, special education staff, 504/ADA staff, and other District personnel with a legitimate educational interest.
• OFC staff, supervisors, interns, contractors, administrative staff, and support personnel who need the information to perform assigned school-support functions.
• Parents/guardians with educational rights under FERPA.
• Emergency responders, child welfare, law enforcement, crisis providers, medical providers, or other appropriate parties when disclosure is permitted or required by law, including safety emergencies, mandatory reporting, court order, subpoena, or other legal process.

Purpose of sharing:

• To provide, coordinate, supervise, document, and evaluate school-based support services.
• To support the student's educational access, safety, functioning, coping skills, social emotional development, behavior support, and school success.
• To communicate with parents/guardians and school staff about general progress, strategies, and support needs.
• To comply with legal, safety, mandatory reporting, and District obligations.

I understand that:

• The District may treat OFC as a school official with a legitimate educational interest if the District's FERPA annual notice and written agreement with OFC support that designation and if OFC satisfies FERPA's direct-control, authorized-use, and redisclosure requirements¹.
• FERPA generally gives parents the right to inspect and review their child's education records, seek amendment of records believed to be inaccurate or misleading, consent to disclosures except where FERPA permits disclosure without consent, and file a FERPA complaint with the U.S. Department of Education Student Privacy Policy Office⁴.

Parent consent form-school-based non-clinical support services.

Page 5

Parent Consent - North Park School District / Olson Family Counseling, P.C.

• FERPA generally requires schools to provide parents an opportunity to inspect and review education records within a reasonable period of time and not more than 45 calendar days after receiving a request⁴.
• OFC will use student information only for authorized school-support purposes and will not redisclose personally identifiable information from education records except as allowed by law, authorized by the District, authorized by the parent/guardian, or required for safety or legal compliance.
• This authorization is voluntary and may be revoked in writing, but revocation will not undo information already shared or actions already taken before the revocation was received.

Expiration of authorization: Unless revoked earlier in writing, this authorization applies for the current school year and any summer programming connected to that school year, ending on: _________________________. If no date is entered, it expires at the end of the District school year in which it is signed.

I understand that Colorado's Student Data Transparency and Security Act addresses student personally identifiable information, data security, data-sharing agreements, vendor contracts, retention, destruction, and limits on commercial use of student data. Colorado Department of Education materials describe requirements for privacy/security safeguards, contract provisions, use of student personally identifiable information only for specified purposes, destruction when no longer needed, limits on further disclosure, and prohibition on commercial use outside the contract scope⁶. OFC will not sell student information, use student information for unrelated marketing, or use student information for purposes outside the District-authorized school support program. OFC will follow District-approved procedures for maintaining, securing, returning, or destroying student information at the end of the program or as otherwise required by the District agreement and applicable law.

The Protection of Pupil Rights Amendment ("PPRA") applies to certain surveys, analyses, or evaluations administered by state education agencies, local education agencies, or recipients of U.S. Department of Education funds and covers protected areas including mental or psychological problems of the student or the student's family, sex behavior or attitudes, illegal or self-incriminating behavior, family relationships, privileged relationships, religion, political beliefs, and income except as allowed by law⁷. If OFC or the District uses a survey, screener, questionnaire, checklist, or similar tool that asks about PPRA-protected topics, I understand that the District may need to provide notice, an opportunity to inspect materials, written consent, and/or an opt-out opportunity depending on the survey, funding source, and whether participation is required. U.S. Department of Education guidance explains that required surveys funded as part of a Department of Education program require signed, dated, written parental consent before participation, while other covered surveys generally require direct notice and an opportunity to opt out⁸.

Parent choice for non-emergency educational screeners/checklists used for this support program:

Parent consent form-school-based non-clinical support services.

Page 6

These services are school-based supports and are not confidential psychotherapy. Information will be shared only with people who have a legitimate need to know for school-support, supervision, safety, legal, or compliance purposes, but privacy has limits. I understand that OFC and District personnel may disclose information without additional parent permission when permitted or required by law, including but not limited to:

• Suspected child abuse or neglect.
• Threats or risk of harm to self or others.
• Medical, safety, behavioral, or school emergencies.
• Court order, subpoena, legal process, or government investigation.
• Consultation, supervision, staffing, documentation, program evaluation, and compliance needs.
• Communication with school officials who have a legitimate educational interest.
• Other situations permitted or required under FERPA, PPRA, Colorado law, District policy, or applicable professional obligations.

I understand that many professionals working with students are mandatory reporters under Colorado law. Colorado guidance identifies public or private school officials and employees, mental health professionals, licensed professional counselors, licensed marriage and family therapists, social workers, unlicensed psychotherapists, and professional candidates among mandatory reporter roles. I understand that a mandatory reporter with reasonable cause to know or suspect child abuse or neglect must report to the Colorado Child Abuse and Neglect Hotline or local law enforcement within 24 hours, and reporting concerns to a supervisor does not relieve the reporter's legal duty to report. I understand that:

• A report may be made without my permission if there is reasonable cause to suspect abuse, neglect, or another legally reportable safety concern.
• Parents/guardians may or may not be notified before or after a report depending on the situation, safety needs, legal requirements, and guidance from child welfare or law enforcement.
• A mandatory reporter generally cannot delegate the duty to someone who lacks firsthand concern, suspicion, or knowledge of the situation.
• A reporter may be immune from liability for good-faith reporting, while failure to report can carry legal consequences under Colorado law.

These school-based support services — whether delivered virtually or in person — are not crisis services, emergency services, suicide risk evaluation, medical care, psychiatric care, or 24/7 support.

Parent consent form—school-based non-clinical support services.

Page 7

Parent Consent - North Park School District / Olson Family Counseling, P.C.

If my child is experiencing a mental health crisis, expressing suicidal thoughts, threatening harm, experiencing abuse or neglect, or is in immediate danger, I understand that I should contact emergency or crisis resources immediately.

• 911: Emergency services.
• 988 Suicide & Crisis Lifeline: Call or text 988.
• Colorado Crisis Services: 1-844-493-8255.
• Colorado Child Abuse and Neglect Hotline: 844-CO-4-KIDS / 844-264-5437.
• North Park Medical Clinic: (970) 723-4255.
• Nearest emergency room: Go immediately if the student is in immediate danger.

If safety concerns arise during school-based support (virtual or in person), OFC and/or District staff may notify school administrators, parents/guardians, emergency contacts, crisis services, law enforcement, child welfare, medical personnel, or other appropriate parties as permitted or required by law and District policy.

OFC support services are intended to use skill-building, observation, de-escalation, consultation, and positive behavioral support strategies. OFC does not independently authorize restraint, seclusion, suspension, expulsion, law enforcement referral, shortened school day, involuntary removal, or disciplinary placement.

Colorado recognizes rules and procedures regarding restraint and seclusion for students, including students with disabilities, through the Protection of Persons from Restraint Act and related school rules². Any restraint, seclusion, emergency safety intervention, discipline, informal removal, shortened school day, or change in placement must be handled by the District according to applicable law, District policy, and, when applicable, IEP/504 procedures.

As noted above, OFC's school-based support services are primarily delivered virtually — typically by secure video, and audio-only when needed — and may also be delivered in person at the school. In both formats, services remain non-clinical educational supports, not psychotherapy or behavioral health treatment.

Please check one:

If I consent to virtual services, I understand that:

• Services may occur by video and, when necessary, audio-only methods.
• Technology disruptions, privacy limitations, and interruptions may occur.

Parent consent form—school-based non-clinical support services.

Page 8

Parent Consent - North Park School District / Olson Family Counseling, P.C.

• Reasonable efforts will be made to maintain privacy, but privacy cannot be guaranteed in every school, home, or technology environment.
• My child must participate while physically located in the State of Colorado unless OFC and the District have approved otherwise in writing.
• Virtual support is not appropriate for emergencies or situations requiring immediate in-person support.
• If there is a safety concern during a virtual contact, OFC and/or District staff may contact parents/guardians, school staff, emergency contacts, emergency responders, crisis services, law enforcement, or child welfare as appropriate.

If I consent to in-person services, I understand that:

• In-person sessions will occur at the school or other District-approved location during the school day or other approved time.
• In-person delivery does not change the non-clinical educational nature of the services.
• The same FERPA, privacy, safety, supervision, mandatory reporting, and District policy provisions in this form apply to in-person sessions.

I understand that OFC and District staff may communicate with me about scheduling, participation, general progress, strategies, concerns, resources, or referrals. Email, voicemail, text, school platforms, and other electronic communication may carry privacy risks. I authorize communication through the contact methods I provided unless I restrict them below.

I understand that electronic communication should not be used for emergencies, urgent safety concerns, or crisis situations.

Please check one:

If yes, preferred contact information:

Parent consent form-school-based non-clinical support services.

Page 9

Parent Consent - North Park School District / Olson Family Counseling, P.C.

I understand that parent coaching, family support, psychotherapy, family therapy, couples therapy, psychological assessment, diagnosis, clinical treatment, or services outside the school-based non-clinical support program may require separate consent, separate privacy notices, separate fees or billing arrangements, and separate determination of appropriateness.

I understand that I remain responsible for:

• Seeking medical, mental health, crisis, emergency, or specialty care for my child when needed.
• Updating the school about relevant safety, custody, medical, legal, or educational information.
• Providing current contact and emergency contact information.
• Informing the District if there are court orders, custody restrictions, protection orders, or legal limits affecting access to student information or participation.
• Communicating concerns about the services to the school contact and/or OFC contact listed below.

I understand that OFC and the District cannot guarantee any particular outcome, improvement, behavior change, academic result, emotional result, safety outcome, or prevention of future concerns. Social emotional and behavioral support can involve sensitive topics, student frustration, emotional discomfort, misunderstandings, incomplete information, differing parent/school perspectives, technology limitations (including those associated with virtual delivery), and the possibility that a student's needs may exceed the scope of non-clinical school support. To the fullest extent permitted by law, I acknowledge these limitations and understand that participation in school-based support does not create a guarantee of safety, wellness, academic success, behavior change, diagnosis, treatment, or prevention of harm. Nothing in this form waives rights that cannot legally be waived, limits legally required reporting, prevents a parent from filing legally protected complaints, or excuses the District or OFC from duties imposed by applicable law.

For FERPA records requests, I understand I should contact the District's designated FERPA/records contact according to District procedures. For IEP, Section 504, disability accommodation, or special education concerns, I should contact the District's special education director, 504/ADA coordinator, school administrator, or other District-designated official.

Parent consent form - school-based non-clinical support services.

Page 10

Parent Consent - North Park School District / Olson Family Counseling, P.C.

This consent is between OFC and the parent/guardian signing below. North Park School District is not a party to this form and is not asked to sign it; the District's authorization to engage OFC for these services is documented in the separate OFC-District agreement.

Parent consent form-school-based non-clinical support services.

Page 11

Parent Consent - North Park School District / Olson Family Counseling, P.C.

Parent consent form - school-based non-clinical support services.

Page 12

Parent Consent - North Park School District / Olson Family Counseling, P.C.

All citation markers in this document refer to the numbered sources below. URLs are clickable.

1. U.S. Department of Education Student Privacy Policy Office - Who is a school official under FERPA?. https://studentprivacy.ed.gov/faq/who-school-official-under-ferpa

2. Colorado Department of Education - Special education rules. https://ed.cde.state.co.us/spedlaw/rules

3. Colorado Department of Education Special education and student health. https://ed.cde.state.co.us/shs/snh-home/snh-specialeducation

4. U.S. Department of Education - A Parent Guide to FERPA. https://studentprivacy.ed.gov/sites/default/files/resourc e_document/file/A%20parent%20guide%20to%20ferpa_508.pdf

5. U.S. Department of Education and HHS- Joint Guidance on FERPA and HIPAA for student health records. https://studentprivacy.ed.gov/resources/joint-guidance-application-ferpa-and-hipaa-student-health-records

6. Colorado Department of Education - State Board obligations on student data privacy and security. https://ed.cde.state.co.us/dataprivacyandsecurity/state-board-obligations

7. U.S. Department of Education Student Privacy Policy Office What is the PPRA?. https://studentprivacy.ed.gov/faq/what-protection-pupil-rights-amendment-ppra

8. U.S. Department of Education - Notice to Superintendents on PPRA. https://studentprivacy.ed.gov/sites/default/file s/resource_document/file/Superintendents Annual NoticeApril2020_0.pdf

9. CO4Kids and Colorado Department of Human Services - Mandatory reporters. https://co4kids.org/child-abuse-prevention/mandatory-reporters/

Parent consent form-school-based non-clinical support services.

Page 13