Earl Boyles Elementary School

Group Counseling Permission Form

Kagan Young, School Counselor Intern

I, _____________________________, give permission for Kagan Young, School

Counselor Intern, to take my child, ____________________________ out of class
for an average of 30 minutes each week for group counseling focused
on________________________________________________________________
(Please note: although the goal is to meet one time per week for six to eight weeks,
due to school events or illness all sessions may not occur). I understand that my
child may be required to make-up the work missed in class. Topics and issues
discussed during the group sessions will be confidential between the
aforementioned student, and Mr. Young, unless a threat of harm to self or harm to
others is determined. At that time, Mr. Young may contact additional people as
deemed appropriate and to ensure the health and safety of the student. If I have
questions or concerns, I may contact Mr. Young via phone at (503)-256-6500 Ext
8109, or by email at kagan_young@ddouglas.k12.or.us. Christine McHone, Earl
Boyles Licensed School Counselor, will provide direct supervision. She can be
reached at the number above or by email at christine_mchone@dds40.org.
_________________________________
Parent/Guardian Signature
_________________________________
Student Name
_________________________________
Kagan Young
School Counselor Intern
Graduate School of Education: Counselor Education
Portland State University

______________
Date
______________
Date
______________
Date