Dear Parent/Guardian,

Your child has been referred for assistance from our School Outreach Counselor. Please check the appropriate response below and sign this form so that your child may be seen individually and/or in a small group by the School Outreach Counselor.

You are welcome to download the form or fill the form online and send to us.

School Consent Form

Yes, I give permission for my child to receive assistance from the School Outreach Counselor.

Check this box.

No, I choose not to use this assistance at this time.

Check this box.

Parent/Guardian Signature

Please enter your name and date here. This is your signature.

Date

YYYY

Preferred Phone

(###)

###

####

Preferred Email

Child's Teacher

First Name

Last Name

Grade Level

Please include any helpful information about your child below.

Please check here if your family receives Medicaid. Medicaid qualification is not necessary for participation in our School Outreach program. This information is confidential and is for billing purposes only.

Check this box.

Thank you.