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Personal Counseling Permission Form

Client Information (For School-Based Counseling)
Parent's Permission and Authorization for Counseling and Disclosure/Exchange of Information

JSerra Catholic High School's Personal Counseling Department offers individual counseling to students. Parents/guardians or school staff may refer students for counseling or students may request counseling. It is policy to obtain parent/guardian written permission for counseling. For any student who sees a counselor, this form needs to be filled out and returned to the personal counselor prior to counseling beginning. In some cases, such as a crisis, the counselor will see a student and obtain permission thereafter.

Counseling can support your child regarding peer relationships, behavior management, anxiety, social skills, substance use/abuse, etc. If there is a need for extended counseling services referrals to outside agencies will be given.

We hope your child will enjoy and benefit from the services we offer, and we encourage you to contact us whenever you have a question, input or concern, or would like an update on your child's progress in counseling.

Cara Morales, MA, LMFT #84336, LPCC #5521
Courtney Harkins, PSYD, LMFT #43611
Matthew Tuszynski, MA, AMFT #121170 supervised by Courtney Harkins

Complete the Form