I agree to allow my child to meet with Ms. Walker, School Psychologist, at Andrew J. Brown Academy for the current academic school year. I agree to allow my child to participate in school psychological services, which may include, but is not limited to: individual counseling, group counseling, psycho-educational groups, social skills groups, and/or behavior interventions lead by the School Psychologist. My child may also schedule meetings with Ms. Walker as well as to meet with her on an as-needed basis during times of emotional distress or behavioral disruptions during the school day.

 

I understand that these sessions are confidential and I will not receive details of my child’s and the School Psychologist’s meetings. However, I understand that I may contact the School Psychologist at any time to discuss questions or concerns and may be provided with general information such as progress and themes (e.g. friend issues, stress, anger management).

 

I also understand that the School Psychologist is a mandated reporter and therefore has a legal obligation to protect the safety of my child and the safety of others. This may include alerting the school administration, local police, or child protective services for confidential reporting, if necessary. It may also include informing me, if my child reports being in a dangerous or abusive situation or if my child expresses intent to harm another person.

 

In addition, school-based psychologists often work closely with school staff to promote student success in school. I understand and provide consent to have Ms. Walker exchange information and records with school staff, solely for the purpose of aiding with this student’s school adjustment and performance.

 

This agreement, unless otherwise specified, is valid for one year from the date of signature. I understand that I may revoke this consent at any time by signing and dating a written notice to that effect.

Confidentiality promotes a more advantageous counseling experience; counseling tends to be most helpful when a student can share his or her thoughts and feelings without concern that such will be shared outside of counseling. As a school-related counselor/ school psychologist, I value confidentiality and will not release and/or discuss information with any other students or staff members without the student’s permission. However, there are some exceptions related to the safety and well-being of a student or others.  Confidential information is not disclosed without written consent, with the exception of the following circumstances:

 

1. There is danger to the student or to others;
2. Mandatory reporting as required by law (i.e., in the case of suspected child abuse or harassment, intimidation and/or bullying);
3. Other release of information as required by law or school policy.

 

If counseling is provided for a student with an Individualized Educational Program (IEP), I am required to share certain information with other Case Conference Committee (CCC) or Multi-Disciplinary Team (M-Team) members (e.g., case manager, Teacher of Record), all of whom will use the information as mandated for special education programming guidelines. Limits to confidentiality are listed below.

 

Reasons a school-related counselor/ school psychologist may break confidentiality with a student are:

 

1. When a student states he or she wants to harm him or herself.
2. When the student reports he or she wants to harm someone else.
3. When a student reports sexual abuse, physical abuse or neglect.
4. When a student reports harassment, intimidation or bullying.
5. When a student is found with the possession of drugs, alcohol or weapons.
6. When a student is suspected to be under the influence of drugs or alcohol.
7. Other situations where the student and/or others are in danger. If another situation arises that necessitates sharing information, you will be informed as to why. Please ask me any questions you may have.

 

 

I have read and consent to my child receiving school psychological services and understand the limits of confidentiality.