Informed Consent Form

Mack Middle School

Huger, South Carolina

____________________________ _________________________________
Date Student’s Name

Introduction
Mack Middle School is committed to providing excellent services to all students. In effort
to achieve this goal, students may be referred for counseling by parents/ guardians or
school staff, or students may request counseling. The focus of the counseling program is
to help students reach their individual goals for their academic achievement, career path,
and personal/social achievement.

Background
Mack Middle School’s counselor is Kristian Watson. Ms. Watson received her master’s
degree in School Counseling from the University of South Carolina. She also received
her Bachelor of Arts degree from the University of South Carolina.

Provision of Services
It is a generally accepted policy to obtain the parent/ guardian’s permission for
counseling when it is requested or I see that it will last longer than one day. This written
permission is kept in a separate file in my office.

Confidentiality
I understand that Ms. Watson will keep information confidential with the following
exceptions:
* IF they are being harmed
* IF they are harming themselves
* If they know of anyone who might be doing harm to themselves.

The student will be informed when that confidentiality has to be broken.

Contact me for questions regarding this consent form.

By signing this form, you are giving our school counselors the right to counsel with them.

________________________________
Parent’s Signature