Release of Information
Consent for Treatment
Counseling Permission

Permission for School Counseling
A parent can be provided this form to receive permission for a child/student to receive indvidual or group counseling services at a school.

Free Permission for School Counseling Form


Permission for School Counseling

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.


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


Parent/Guardian Email

Daytime Phone Number