Permission Form for Group

Dear Parent/Guardian
Your child has been selected to participate in a group focusing on_______________________.
He/She has been informed and would like to join the group. They will be discussing the selected
topic to help improve that area of their life. There are some ground rules set for the group.

1. Each participant must agree to the rules of confidentiality.

2. Each participant must agree to listen to the other group members point of view as well as
expressing their own.
3. Each participant must agree to solve any conflicts that may arise in a calm and
appropriate manner.
4. Each participant must understand that if they fail to follow these rules they may be exited
from the group at the discretion of the school counselor.
The group will meet once per week during advisory period. I feel that your child would benefit
from being a member of this group. He/She needs your permission to join the group. Please sign
this permission form and return to school with your student.

Confidentiality

The process of counseling is dependent upon trust between the counselor and the child/ren. One
of the most powerful ways to build trust is for the counselor to maintain confidentiality of what
is discussed during the group session. To this end Miss Allen will keep what is discussed
between the group and herself confidential EXCEPT the following cases:

1. These is a clear and imminent danger to your child or others.

2. The information relates to mental or physical abuse.
3. A court orders the release of the information.
4. The information relates to criminal activity.

Thank you,
Kendra Allen
Counselor

I (parent/guardian)____________________________, give my child___________________,

permission to participate in group counseling.

Parent/Guardian signiture____________________________________ Date______________