Informed Consent

  • Antioch Unified School District is committed to providing quality education to its students. In an effort to achieve this goal, parents/guardians or school staff may refer students for counseling, or students may request counseling. School counseling is considered a regular educational service and therefore students can be seen without parent consent. However, as a good faith practice the counselor will not see students in a group setting without first receiving parent permission. In addition, school counselors are not able to provide long-term intensive mental health therapy services to students. The school counselor would be happy to provide information about community resources if you feel your student is in need of additional support. As a parent or guardian you have the right to decline certain educational services such as school counseling. If you do not want your child to be seen individually or in a group setting, please contact the school Principal and provide a written statement or decline services below on this form. Please read the form carefully. Feel free to contact the school counselor with any questions that you may have
    “The School Counseling Credential authorizes the holder to: 1) develop, plan, implement and evaluate a school counseling and guidance program that includes academic, career, personal and social development; 2) advocate for the high academic achievement and social development of all students; 3) provide school-wide prevention and intervention strategies and counseling services; 4 ) provide consultation, training and staff development to teachers and parents regarding students' needs; and 5) supervise a district-approved advisory program as described in Education Code Section 49600"

    Provisions of Services
    It is the policy of John Muir Elementary to obtain parent/guardian written permission for individual counseling that extends beyond periodical check-in meetings or that is planned on a regular basis. Services include short-term individual counseling, crisis intervention, group counseling, and referrals as needed. Counseling services take place during regular school hours and will be provided by the school counselor and/or the school counselor intern free of charge. Students will work on academic, social, emotional, and behavioral goals as they relate to school. For approximately 6-9 weeks, students practice and review our school rules, friendship skills, problem solving skills, mindfulness, and more in a supportive environment. It is understood that school counseling services are aimed at helping students within their educational journey as part of our school community. It is understood that these services are not intended as a substitute for psychological counseling, diagnosis, or medication.

    Confidentiality
    In order to build trust with the child, the school counselor will keep information confidential with some possible exceptions. I understand that the counselor may share information with parents/guardians, the child’s teacher, administrators or school personnel who work with the child on a need to know basis, so that we may better assist the child as a team.
    The counselor is required by law to share information in the following circumstances:
    • School counselor feels that your child is in danger of harming him/herself or others. Every effort will be made to work with you and inform you first in such a case.
    • Instances of previously unreported sexual or physical abuse of a minor or elder are brought to light, California state law requires the school counselor to report this information to the proper authorities or assist you in making such a report.
    • Threats to school security
    • In the case, counseling records are court ordered by subpoena, the school counselor will attempt to contact you first. However, he/she must comply with the court.
    The counselor will make the child aware of these limits of confidentiality and will inform the child when sharing information with others.

    Limits to Confidentiality (during distance learning)
    It is understood that there are risks and consequences from virtual school counseling that are beyond the control of the school counselor.
    Although the internet provides the appearance of anonymity and privacy in counseling, privacy is more of an issue online than in person. Texting, e-mail, phone calls and videoconferencing aren’t fully secure modes of communication. Please understand the potential risks of confidentiality being breached through your personal unencrypted email, lack of password protection or leaving information on a public access computer. Other potential risks of breaching confidentiality could include messages failing to be received if they are sent to the wrong email address. Confidentiality could be breached in transit by an unauthorized person, internet service providers or by others with access to the guardian’s or student’s account/ computer. Students/ Guardians accessing the internet from public locations or shared locations with the home should consider the visibility of their screen to people around them.

    The counselor has a right to his or her privacy and may restrict the use of any copies or recordings the client makes of their communications. Students, Guardians and or any other person associated with the student must seek the permission of the counselor before recording any portion of the meeting. It is strictly prohibited to post edited or unedited meetings, images of the counselor or counselor communication on the internet.
    If you would like the counselor to share information with a third party, such as a community counselor, psychiatrist, social services worker, or pediatrician, you will need to sign an additional release of information form.

    Discontinuation of Services
    Students and parents have the right to discontinue counseling at any time without any legal or moral obligations. The counselor has the right to discontinue counseling with students under the following conditions:
    1. When it is determined counseling is no longer beneficial to the student
    2. When it is determined that another professional might be able to better serve the student
    3. When the student refuses to cooperate with the proposed counseling treatment plan
    If any of these situations apply, the counselor will inform the student directly, and contact parents/guardians to inform them of the decision.

     

     

    To complete the actual Informed Consent please complete the digital form here: https://docs.google.com/forms/d/e/1FAIpQLSfAoE_ZbHqHgAuBK05rAaVuTJmTgpLtBTG897XBl4DvZ40TOQ/viewform

    (If you cannot complete the digital form, please contact the counselor) 

Group Permission

  • ***This is a sample of the actual form for translation purposes. Please contact the counselor if you are interested in your child participating in a group****

     

    As the school counselor, I offer all students the opportunity to participate in classroom guidance lessons throughout the year. These lessons help to support the social and emotional development of students, bully prevention, conflict resolution, and college/career development. These lessons have a positive influence on academic development and success. In addition to classroom lessons, I offer small groups that are aligned with our school goal of positive behavior intervention support (PBIS). I schedule groups based on need and grade level. Beginning in mid-October (additional groups will be added in the spring) each group will meet on a weekly basis for 6- 9 weeks. Each meeting will be 20- 40 minutes in length and will take place during the school day.

    During group meetings, children will have the opportunity to learn new skills and behaviors through discussion of ideas, feelings, behaviors, attitudes, and opinions. The children will participate in a variety of activities relating to the group topic. These activities may include drawing, role-playing, relaxation exercises, and practicing new behaviors. Your child may also be asked to practice their new skills with family members and friends. For example, your child may be asked to practice telling you how they feel, or may be asked to practice deep breathing.

    As the guardian, please feel free to contact me to discuss your child and his or her growth in the group. However, I do encourage parents to speak with teachers about classroom progress or their student directly. Even though the students are minors, I work very hard to establish trust and this can easily be broken if students feel as if I am reporting everything said in group back to their guardians.  Other than sharing with a guardian about their own student (upon guardian request) groups are considered confidential unless district policy and/or ethical responsibilities require disclosure. These circumstances were indicated in the informed consent form (previously signed).

    In order for your child to participate in a group, I will need to have written permission from you. Please complete the form below and return to me. As always, if you have questions or concerns, please contact me at 925-779-7450 or ashleeoneal@antiochschools.net  

    Mrs. Ashlee O’Neal

    M.Ed School Counseling & Clinical Mental Health Therapy

    Licensed Associate Counselor, PPS

     

    Child’s Name                                                                Teacher’s name:                                                           

     

    Group focus that student will be participating in: _______________________________________________

     

    Please select one:

    I give consent for my child to participate in group counseling. I understand that:

    • The group will provide an opportunity for members to learn and practice interpersonal skills, discuss feelings, share ideas, practice new behaviors, and make new friends.
    • Where possible, information shared during group meetings will be kept confidential by the group leader and the other group members.

     

    ☐I do NOT give consent for my child to participate in group counseling, I understand that:

    • I am refusing an intervention recommended based upon data or staff recommendation.
    • My child may receive consequences based upon their behavior in the classroom or on the playground.

     

    Parent/Guardian Signature:                                                                       Date:                                 

    Email:                                                                                         Phone number:                                              

Disclosure Statement



  • As a parent or guardian you have the right to decline certain educational services such as school counseling. If you do not want your child to be seen individually or in a group setting, please contact the school Principal and provide a written statement.

    School counseling is considered a regular educational service and therefore students can be seen without parent consent. However, as a good faith practice I will not see students in a group setting without first receiving parent permission. I also will not provide mental health therapy services to students, but I would be happy to provide information about community resources if you feel your student is in need of additional support.

    The Pupil Personnel Services: School Counseling Credential authorizes the holder to: 1) develop, plan, implement and evaluate a school counseling and guidance program that includes academic, career, personal and social development; 2) advocate for the high academic achievement and social development of all students; 3) provide school-wide prevention and intervention strategies and counseling services; 4 ) provide consultation, training and staff development to teachers and parents regarding students' needs; and 5) supervise a district-approved advisory program as described in Education Code Section 49600"

Limits to Confidentiality (during distance learning)

  • It is understood that there are risks and consequences from virtual school counseling that are beyond the control of the school counselor.

    Although the internet provides the appearance of anonymity and privacy in counseling, privacy is more of an issue online than in person. Texting, e-mail, phone calls and videoconferencing aren’t fully secure modes of communication. Please understand  the potential risks of confidentiality being breached through your personal unencrypted email, lack of password protection or leaving information on a public access computer. Other potential risks of breaching confidentiality could include messages failing to be received if they are sent to the wrong email address. Confidentiality could be breached in transit by an unauthorized person, internet service providers or by others with access to the guardian’s or student’s account/ computer. Students/ Guardians accessing the internet from public locations or shared locations with the home should consider the visibility of their screen to people around them.

    The counselor has a right to his or her privacy and may restrict the use of any copies or recordings the client makes of their communications. Students, Guardians and or any other person associated with the student must seek the permission of the counselor before recording any portion of the meeting.  It is strictly prohibited to post edited or unedited meetings, images of the counselor or counselor communication on the internet.

    If you would like the counselor to share information with a third party, such as a community counselor, psychiatrist, social services worker, or pediatrician, you will need to sign an additional release of information form.