School Counseling Information and Informed Consent Form
for the 2014-2015 academic year
Chandler Intermediate School
Brownsboro Independent School District
Overview of the school counseling program
The school counseling program at Chandler Intermediate School is designed
to assist your child to make the most of his or her educational experiences. As
your child's counselor, I am concerned about his or her emotional well-being,
academic progress, and personal and social development.
This information is intended to provide you with important information about
the counseling program, the counseling relationship, and rights and
responsibilities involved in the counseling service. Please read this
information carefully, and feel free to contact me with any questions you may
have regarding the information contained within. It is the policy of the
Brownsboro Independent School District to obtain parent/guardian written
permission for counseling that extends beyond two sessions in a school year
or that is planned on a regular basis. The final page of this informed
consent form may be returned to the school.
Professional qualifications and experience of the school counselor
My name is Stephanie Stevens. I am a licensed school counselor certified by
the Texas State Board of Educator Certification. I have a Master's (M.Ed.)
degree in school counseling from Lamar University. In addition, I have a
Master's (M.Ed.) in Educational Administration and hold certification as a
principal, grades EC-12. Before serving as a counselor at Chandler
Intermediate School, I was an elementary teacher (grades 3-5), a junior high
teacher (grades 6-8), an educational consultant (Region VII Education Service
Center), a reading interventionist (elementary and intermediate grades), an
assistant principal (grades 6-8), and a student support services coordinator
(grades 4-6). I maintain active membership in the American School
Counselors Association (TSCA). It is my privilege to serve your student,
community, and this school.
Role of the school counselor
The school counselor, in cooperation with teacher, staff, and administrators at
Chandler Intermediate, is responsible for providing a comprehensive school
guidance program for students enrolled in grades 4 through 6. A
comprehensive, developmental guidance program is the cornerstone of an
effective school counseling program. Components of the program align with
the American School Counseling Association's National Model and include
school guidance curriculum, individual student planning and counseling
services, responsive counseling services, and system support services. Each
component of the program is outlined below:
Guidance curriculum
Classroom guidance delivers services to larger groups, and it consists
of classroom lessons that emphasize wellness-based activities that
address topics in a preventative manner.
Individual student planning
Individual student planning involves test information, student data, and
achievement information for the purpose of developing immediate and
long-range goals or intervention efforts for academic success of
individual students and student groups. Screening students for special
program consideration (with exception to special education services) is
also considered
Responsive services
Responsive services involve both direct and indirect services to
students. The methods of service delivery for responsive services are
individual counseling, group counseling, consultation, referrals, crisis
response, and peer facilitation.
Individual counseling sessions involve offering direct, short-term
service to students to address both proactive and reactive needs.
Small-group counseling is a direct short-term service designed
to respond proactively and reactive to student needs. This format of
psychoeducational service offers a variety of small-group experiences
on relevant and developmentally appropriate topics such as study skills,
anger management, grief, social skills, and other needs-based
academic or personal development issues.
Consultation is an indirect service which involves collaboration
with administrators, teachers, parents, and other counseling
professionals to address student issues or concerns. The purpose of
consultation is to discuss curriculum planning, addressing academic or
behavioral interventions, provide training for faculty and staff, assist in
coordinating mental health services for students and parents, or
planning policy guidelines.
Referrals involves enlisting the services of other professionals to
assist students in handling complex issues that are beyond the scope
and level of expertise of the school counselor.
Crisis response involves immediate and critical intervention to
an acute situation. The purpose of crisis counseling interventions is to
diffuse a situation, serve school and community members affected by
the situation, and promote a healing process. The school counselor, in
coordination with a crisis response team, will provide direct services
such as group or individual counseling and indirect services such as
crisis planning and referrals.
Peer facilitation involves cultivating leadership skills in students.
This direct services involves a peer helper program which focuses on
interpersonal skills in the context of leadership and helps empower
students to learn about helping themselves and others. Peer facilitation
may be provided as part of a classroom guidance curriculum or as an
extracurricular activity.
Systems support services
Systems supports involves administration and management of an effective
comprehensive school counseling program, and it involves the school
counselor in tasks to support the program.
Confidentiality and its limits
Your child will be participating in the school counseling program on a regular
basis, and it may involve short-term individual or group counseling.
Confidentiality is a key feature of the counseling relationship with students. In
order to build trust with your child, I will keep information confidential, with
some possible exceptions. The information discussed during the counseling
meetings will not be shared with anyone except in situations required by law
or those specifically addressed in school policy. These situations are
described below:
 In the case that the school counselor believes that your child is in
danger of harming him/herself or others, the counselor is
required to take action. Every effort will be made to cooperate
with parents/guardians and inform them first in such a case.
 If instances of sexual or physical abuse of a minor or elder are
revealed, Texas statutes requires the school counselor to report
this information to the proper authorities.
 If counseling records are court-ordered, the school counselor
will make every effort to comply, cooperative with designated
parents/guardians, limit the information revealed, and reduce
the impact of breaching confidentiality.
 School policy specifically addresses the notification of
administrators if the school counselor has knowledge of students'
at-risk behaviors which might present potential damage or
disruption of the school environment. Every effort will be made
to inform parents/guardians in such a case.
 It is the school counselor's responsibility to provide quality care
to your child. In order to ensure that quality of care is being
provided, consultation with a colleague may be necessary.
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During this consultation, every effort will be taken to protect the
identity of your child.
If students participate in group counseling, limits and
responsibilities of group members to maintain confidentiality are
discussed and emphasized. However, inadvertent breaches of
confidentiality are always a risk. Intentional breaches of
confidentiality will have consequences. If the school counselor is
aware of any confidential information that has been disclosed,
she will make every effort to remediate the situation and notify
parents/guardians of the breach. Separate, more specific
informed consent will be obtained from students and
parents/guardians prior to the student participating in group
counseling sessions.
If requests, referrals, or other information about students is
transmitted electronically (via phone, fax, or email), privacy
cannot be guaranteed. Referrals submitted in writing will be
considered confidential and treated as such. However, sensitive
or confidential information submitted or forwarded to the school
counselor always carries the risk of being accessed by
unauthorized persons. Every effort will be made to preserve
confidential information of students and their families.
Parent/guardian rights involved in the school counseling program
Although the information shared during a counseling meeting is confidential,
parents/guardians have a right to be informed of their child's general
progress. I am required by law to share information with parents and
authorities in the event the child is in danger of self-harm or the harm of
others. The student and the parent/guardian has the right to refuse
counseling services or involvement in the school counseling program at any
time. Refusal of counseling participation or services must be documented in
writing.
Referrals/arrangements for counseling services
Referrals and requests for counseling services may be arranged or submitted
by parents/guardians, school auxiliary staff, teachers, or other administrators.
These requests made be made in writing, by electronic means, or in person.
Arrangement for counseling services will be considered based on individual
need.
Limitations to school counseling services
The school counselor's direct services to students will be provided during
school hours. Consultation, crisis response services, referrals, reports, and
other indirect services may involve the school counselor in after- or beforeschool activities. Unfortunately, the school counselor is not authorized to
provide private counseling to students, parents, or families, provide intense
or long-term counseling services, make diagnosis of mental disabilities, or
accept fees or gifts for services. The school counselor will provide indirect
and direct services to students in a professional manner consistent with the
ethical standards outlined by the American Counseling Association and the
Texas School Counselors Association. Participation in counseling services
does not guarantee specific results; however, research supports the benefit of
students' involvement in comprehensive school counseling programs.
Making inquiries regarding the school counseling program
If you have further questions about the information provided in this form, the
counseling relationship or your child's progress, please contact the school
counselor at (903) 849-6436 during school hours.
Please review and sign the informed consent form included in
this document (see next page).
School Counseling Informed Consent Form
for the 2013-2014 academic year
Chandler Intermediate School
Brownsboro Independent School District
Please review the information provided in this document, sign according to
the instructions to indicate agreement, and return to the school.
I, (printed name) _______________________________________, am the legal
parent/guardian of (printed student name) ________________________________.
I have read and understand the information provided in this document. I
given my consent to the terms of this document and agree to the following
(check items to indicate agreement) participation.
I give consent to my child's participation in:
_____ School guidance curriculum (classroom activities).
_____ Small-group counseling (by referral).
_____ Individual counseling (by referral).
_____ Peer facilitation activities
I understand that I may withdraw my consent at any time by signing and
dating a written note requesting termination of counseling services.
Parent/guardian signature: ______________________________________________
Date: _____________________ Daytime phone: _____________________________
E-mail contact: _________________________________________________________
PLEASE RETURN THIS SIGNED DOCUMENT TO THE SCHOOL.