School-Based Counseling Consent and Intake Form
Student Information
Student Name
Date of Birth
Grade
School Name
Parent/Guardian Information
Parent/Guardian Name
Relationship to Student
Phone Number
Email Address
Reason for Referral
Please describe the reason for counseling
Relevant Background Information
Please share any relevant background information
Services Requested
Individual Counseling
Group Counseling
Crisis Intervention
Other
Consent to Participate
I have read and understand the information regarding school-based counseling services and give permission for my child to participate.
Parent/Guardian Signature
Signature
Date