Counseling Program Student Information Form

Student Namerequired

First Name

Last Name

D.O.B:required

Name of Parent/Guardianrequired

First Name

Last Name

Address (physical)required

Address (mailing)required

Student is living with (name and relationship to student):required

Phone Numberrequired

Sibling(s) - please list name, age, gender

Other information that you want to share with the counselor:

What counseling outcome(s) do you expect to see?required

Please list any additional information that you feel might be helpful (i.e. interventions already tried that worked even for a short time):

Interventions tried unsuccessfully:

Is your child receiving counseling somewhere else?required

Yes

No

Terms of Servicerequired

I would like for the school counselor to speak with my child regarding the concerns noted on this form. I understand that the school counselor works closely with my child’s school and that information learned about my child may be shared with the principal, nurse, behavior coach/FCT and my child’s teacher in order to help my child succeed in school. I understand the counselor may access my child’s school records. When my child moves on to her/his next school, the counselor often passes on the name so the next school’s counselor will work with the child. This information is given voluntarily and may be revoked by me in writing at any time.

In This Section

Counseling Student Information Form

Forms

Counseling Program Student Information Form

Navigation