SUPPORT SERVICES Parental Informed Consent

Online Form: SUPPORT SERVICES Parental Informed Consent

Step 1 of 2

  • Premier Academy, along with various outside providers, offers individual and group counseling services to students who are enrolled. We are hoping to work with your student during this school year. When your student participates in counseling, he or she will have the opportunity to explore personal strengths and gain knowledge about different problem solving techniques. All information from the counseling relationship will be confidential, within reason. Any concerns regarding these services can be directed to Becky Peterson at 815-416-0377 ext. 1200.

    Confidentiality and Limits of Confidentiality

    Trust and honesty are critical to the development of all counseling relationships. For this reason, we place high value on the confidentiality of information shared in sessions. You should be aware that legal requirements specify certain conditions in which it may be necessary for the school or counselor to discuss information about the student with other professionals. If you have any questions about these limitations, please ask the Premier Case Manager. Such situations include but are not limited to:

    1. Concern that your child may harm him/herself or others.
    2. Reported or suspected abuse victimization: Physical, sexual, mental, medical, neglect.
    3. Reported or suspected abuse perpetration of: Children, elderly, or disabled persons.
    4. Court mandated action.

    It is also important to note that on some occasions it will be in the best interest of your child that the counselor discusses information with other support staff both at Premier Academy and with your child’s home school.

  • I agree that I have read the above information and that the nature of the sessions were explained.

    I hereby consent to have the student listed on this form counseled at Premier Academy.

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