East Bay Collaborative -- Career Academy Consent for Counseling

Group and individual counseling are available for all students at East Bay Career Academy (EBCA). These sessions are either given or supervised by a licensed school psychologist. Although issues of mental health and general adjustment are frequently discussed, these sessions are meant to supplement, not replace, any counseling that the student may be receiving from sources outside of EBCA (such as from a clinic or private therapist).

To insure that the student benefits from any counseling experience, it is essential that the EBCA psychologist and the student�s outside therapist (if there is one) are able to communicate with each other. Therefore, the attached release form must be signed. The sessions at EBCA are held in confidence. However, as provided by law, parents or other authorities will be contacted should a serious question of physical safety arise.

I have read and understand the above. I give my consent to have my child participate in EBCA counseling as outlined.

Release of Information

For

Name of student Date of birth

Name of student if 18 years or older. Parent or guardian if under 18

give the East Bay Career Academy and

Name Address Phone

permission to exchange educational, medical, and psychological information about

�Myself� if over 18, �My child� if under 18 Name of student

Signature Relationship to student Date

Witness:

Signature Date