School Counseling Informed Consent


Your permission is requested for your daughter to participate in the services provided by the counseling program at Maryvale Preparatory School with the school counselor. The Maryvale counseling program provides students with individual counseling, academic counseling, small group counseling, and classroom guidance lessons. All of the services provided to students will assist with the school’s mission to guide the whole child in her development personally, academically, and as a member of this community. School counseling services are designed to be short-term and cannot be substituted for mental health treatment.

The counseling relationship is built on trust between the counselor and students. In order to keep that trust, the counselor will keep information shared by students confidential with few exceptions. When it is deemed necessary to ensure the wellbeing of the student and keep daily functioning as easy and normal as possible, the counselor may discretely share information with parents/guardians, administrators, and teachers so that we may serve the student as a team. By law, the counselor is a mandatory reporter, and to ensure the safety of every child and the members of the community, if a student discloses intent to harm herself, another individual, or that she is being harmed, it will be reported to the necessary authority and to the parents. Students will be notified when confidential information is being shared with others.

 Please inform the counselor in written form if information shared by students should be disclosed to a third party, such as a psychiatrist, counselor/therapist, social services worker, or pediatrician.


I give permission for my student to receive school counseling services at Maryvale Preparatory School for the 2015-2016 School Year. I understand that I may withdraw my consent at any time by signing and dating a written note, requesting termination of counseling services.​​​​​​​
I choose to decline school counseling services for my child at this time. I understand that I may request counseling services at a later date if needed.​​​​​​
By typing your name, you are signing this consent form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this form. 
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