Student Name __________________________________________________________ Date of Birth _____/_____/______ MCPS ID# __________
Name of School _______________________________________________________________________________________ Grade level _________
Parent/Guardian Name _______________________________________________________________ Contact Phone No. ______-______-_______
Purpose ______________________________________________ Duration of Services ____________________ Length of Each Session ________
The school counselor, psychologist, or social worker can provide regularly-scheduled or an ongoing series of individual counseling sessions to
students with permission from the parent(s) or guardian(s). These counseling sessions are designed to teach skills to help students be more
successful in their academic and social environment. Many students may improve their school performance, attendance, and attitude towards
school by taking part in individual counseling sessions. Self-help issues developed in these counseling sessions often include coping strategies,
stress management, problem solving, and social skills. These sessions are not intended to replace non-school based counseling that you may
arrange for the student. Please note that this consent is not necessary for every visit or drop in that a student makes to a school counselor,
psychologist, or social worker; consent is only required for regularly-scheduled or an ongoing series of individual counseling sessions. This does
not include visits exclusively regarding course scheduling or college and career planning.
Information disclosed by the student during counseling sessions is typically not revealed to anyone else, except under certain circumstances
(for example, evidence that a student is a threat to themselves, others or property). Sharing of information will be limited to those MCPS
administrators or other MCPS staff as necessary for student well-being and to support student success. In addition, information must be shared
if legally required to do so. Otherwise, all material discussed will be confidential.
Counseling sessions may be conducted in-person or virtually. There are potential benefits and risks of virtual counseling (e.g. limits to patient
confidentiality) that differ from in-person sessions. Confidentiality still applies for virtual counseling services, and neither party will record the
session without the permission from the others person(s). If it is agreed upon to use the virtual platform the MCPS Counseling provider will
explain how to use it. The student will need to use a webcam or smartphone during a virtual session. It is important to be in a quiet, private space
that is free of distractions (including cell phone or other devices) during the session. It is recommended to use a secure internet connection rather
than public/free Wi-Fi. The MCPS Counseling provider will develop a back-up plan (e.g., phone number where the student can be reached) to
restart the session or to reschedule it, in the event of technical problems. The MCPS Counseling provider will need a safety plan that includes at
least one emergency contact and the closest emergency room to your location, in the event of a crisis situation. The MCPS Counseling provider
may determine that due to certain circumstances, counseling is no longer appropriate and that we should resume our sessions in-person.
This consent for counseling is valid for one school year. Student participation in counseling is strictly voluntary and consent may be withdrawn by
the student’s parent(s)/guardian(s) at any time (or by an eligible student). Parents are encouraged to contact the school counselor, psychologist,
or social worker to keep informed about the student’s progress.
Thank you for your support in helping your child succeed at school.
□
I do give permission for ____________________________________________________________to receive individual counseling services.
(Name of Student)
□
I do not give permission for ________________________________________________________to receive individual counseling services.
(Name of Student)
Parent/Guardian/Eligible Student Name (Print) ________________________________________________________________________________
Parent/Guardian/Eligible Student (Signature) ___________________________________________________________ Date _____/_____/______
MCPS Counseling Provider Name (Print) ______________________________________________________________________________________
MCPS Counseling Provider (Signature) _________________________________________________________________ Date _____/_____/______
MCPS Counseling Provider phone number______-______-_______ and email
______________________________________________________
Consent for Individual Counseling
Office of Student and Family Support and Engagement
MONTGOMERY COUNTY PUBLIC SCHOOLS
Rockville, Maryland 20850
MCPS Form 339-1
May 2020
Distribution: 1/MCPS Counseling Provider; 2/Student Confidential File; 3/Parent/Guardian/Eligible Student
If you have any questions, please call the Office of Student and Family Support and Engagement (OSFSE), at 240-740-5630. Thank
you for your support in helping your child succeed at school.
