Permission for School Counseling
[SCHOOL NAME]
I, [First, Last Name], [Name School District] elementary school counselor, will be conducting individual and group
counseling with students this school year. I support these students with social, emotional, academic, and/or behavioral
concerns at school. If your student has concerns in the home environment, I can provide a list of outside therapists for
you to contact. I am available during my daytime office hours to meet with parents and caregivers to support and problem-solve
any concerns you might have. Please feel free to contact me at [Email Address] or at [Phone Number] any time.
Counseling groups and individual counseling sessions topics include friendships, anxiety, self-esteem, grief, divorce,
anger, conflict resolution, bullying, and more. I meet with students on a short-term basis in which their couseling
needs and progress will be constantly accessed. The counseling sessions will occur during the school day at an agreed
upon time with the classroom teacher. I usually do not meet with students during important academic instruction or
assessment. I also collaborate with classroom, special-education, reading and specials teachers to help the students
learn at their personal academics and social/emotional abilities.
All information is confidential and is disclosed with written permission except when the student is dangerous to
themselves, others and/or is otherwise required by law. Please note, that I will do my best to contact you when
counseling takes place. However, at times, immediate counseling is needed and will take place at the school as
required by the situation. You are always welcome to call or email me at any time. I am at [School Name] on [Days].
Feel free to set up an appointment anytime during the school year.
Sincerely,
First, Last Name
School Counselor
Yes ____
I give permission for my child to participate in individual or group counseling.
No ____
I do NOT give permission for my child to participate in individual or group counseling.
Student's Date of Birth: ______________
________________________________
Parent/Guardian Name
________________________________
Parent/Guardian Signature
________________________________
Date
________________________________
Parent/Guardian Email
________________________________
Daytime Phone Number
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