Introduction
A new addition to Renton Prep for the 2020/2021 school year is school counseling. Parents/guardians or school staff may refer students for counseling, or students may request counseling. The focus of the counseling program is to help students better understand the world they live in and make better decisions that help them live functional lives. There is no cost for counseling services provided through Renton Prep.

Background
Reverend Benita Weems holds a license as a Mental Health Counseling Associate in the state of Washington and holds Master’s Degrees in Clinical Mental Health, Secondary Language Arts Education, and a Master of Divinity. Rev. Weems has experience as a teacher, ordained minister, and currently works in a private practice setting as a counselor.

Provisions of Services
It is the policy of Renton Prep to obtain parent/guardian written permission for individual counseling in a school year. Services may include intake, short-term individual counseling, crisis intervention, group counseling, psychoeducation, and referrals as needed. Any in depth counseling or extensive evaluation and diagnosis will be given referrals.
Agreement*
- By checking this box, I understand school counseling services are aimed at the more effective education and socialization of my child within the school community. I understand that these services are not intended as a substitute for psychological counseling, diagnosis, mental health disorders, or medication, which are not the responsibility of the school. I acknowledge that it is my responsibility to determine whether additional or different services are necessary and whether to seek them for my child.
Benefits/Risks*
- By checking this box, understand that there may be both risks and benefits associated with participation in counseling. Counseling may improve my child’s ability to relate with others, provide a clearer understanding of himself/herself, along with values, goals, and an ability to deal with everyday stress. I understand that counseling may also lead to unanticipated feelings and change, which might have an unexpected impact on my child and his/her relationships.
Confidentiality*
- By checking this box, understand that in order to build trust with the child, the school counselor will keep information confidential with some possible exceptions. I understand that the counselor may share information with Renton Prep administration, staff, and teachers, but only as it is necessary to the well-being or better education of the child. Any information given by the counselor regarding the student to the parents/guardians, the child’s teacher, and/or administrators or school personnel who work with the child on a need to know basis, so that we may better assist the child as a team. The counselor is required by law to share information with parents or others in certain circumstances:
  • Presenting a serious danger to self or another person
  • Evidence or disclosure of abuse (physically or sexually) or neglect
  • Threats to school security
  • Criminal or delinquency proceedings are pending
  The counselor will make the child aware of these limits of confidentiality and will inform the child when sharing information with others. If you would like the counselor to share information with a third party, such as a community counselor, psychiatrist, social services worker, or pediatrician, you will need to sign an additional release of information form.
Contact*
- By checking this box, understand that I am entitled to ask questions and receive information about methods or techniques used by the counselor and the length of counseling, but not about the content of actual sessions. I am free to seek a second opinion or end counseling at any time. I also understand that any contact between with the counselor with the use of technology such as email or by phone cannot be considered 100% confidential. While the counselor will keep confidential any information that is shared via email or phone, technology comes with its own risks that cannot be guaranteed (I.e. hacking, virus, etc...).
Consent
Child’s Name
Child’s Age
Child’s Teacher
Child’s Grade
Informed Consent*
- By checking this box, I affirm am the legal parent/guardian of the child listed above. I have read, understand, and agree to the terms of the School Counseling Informed Consent.
Please check one:*
- I give permission for my child to receive individual and/or group counseling services while attending Renton Prep (If your child is invited to join a recurring group, you will receive additional information at that time.) I understand that I may withdraw my consent at any time by signing and dating a written note requesting termination of counseling services.
- I choose to decline school counseling services for my child at this time. I understand that I may request counseling services at a later date if needed.
I give permission for the School Counselor to contact me and leave a message via:
- email
- phone
- voicemail
- written note
Daytime phone:*
Cell phone:*
Email:*
Custodial Parent/Guardian Signature:*
Date
MM slash DD slash YYYY
Confidentiality agreement
Limits to confidentiality
• In some legal proceedings a judge may issue a court order. This would require this counselor to testify in court.
• If I learn of or believe that there is physical or sexual abuse or neglect of any person under 18 years of age, I must report this information to county child protection services.
• If I learn of or believe that an elderly person, or disabled person is being abused or neglected, I must file a report with the appropriate state agency that handles elder abuse.
• If I learn of or believe that you are threatening serious harm to another person, I am obligated to report this. This can be in the form of telling the person who you have threatened, contacting the police or placing you into hospitalization.
• If there is evidence that you are a danger to yourself and I believe that you are likely to kill yourself unless protective measure are taken, I may be obligated to seek hospitalization for you or to contact family members or others who can help provide protection.
• There may be times when I consult with outside sources about cases. In these cases, no personally identifiable information will be used to discuss this case. However, discussion topics will be used in order to ensure that I am getting and giving the best assistance possible. The persons with whom I discuss cases are legally bound to keep information confidential.
Confirm Confidentiality*
- I have read and discussed the above information with my child/student. I understand the nature and limits of confidentiality.
Student Signature (if able)
Date
MM slash DD slash YYYY
Client signature
Date
MM slash DD slash YYYY

School Counseling Informed Consent Form

School Counseling Informed Consent Form

Consent

Confidentiality agreement

Forms

Resources