On School Letterhead
Date
(Address would go here, if necessary)
Dear Parent or Guardian:
The School Name School Counseling Program provides developmental guidance and counseling for our
students. One component of our program is curriculum based - Small Group Counseling which is
effective process of working with a small group of students with similar concerns to improve school and
personal success. These groups generally meet for about 50 minutes once a week for about 6 weeks,
depending on the needs and progress of the group.
Group counseling has unique strengths due to the significance of peer interaction during the adolescent
years. It is a method of helping students become more comfortable with, receptive to , and aware of
those around them. By talking, listening, and sharing various concerns that arise in their daily
experiences at school, students find new ways of coping with the stresses of growing up and or finding
solutions to school and/or personal problems. Topics at the weekly group meetings may center on
social interactions, academic skills, stress or other common issue that sometime serve as barriers for
students. Information shared during the group is confidential and will not be shared with others outside
the group.
Your child is invited to join our counseling group to be held during the school day at ________ School.
We will meet _____ for the next ____. You may contact the counseling department email or phone if
you have any questions or desire to discuss specifics of the program and the benefits of your child
participating.
Since your school will be missing 50 minutes of each of his classes one time over the next six weeks, we
would like you to give your permission for your child to participate in the group. Please return the
attached form in the enclosed envelope by _______ if you want your child to participate.
Sincerely,
_____________________________
, School Counselor
School Letter Head
I have discussed this decision with my child, _____________________,
and give my permission for him/her to participate in group counseling
at
_________________School for the
____________ school year. I also understand that issues discussed in
group counseling are to remain confidential except when disclosure is
required to prevent clear and imminent danger to the student or others
or when legal requirements demand that confidential information be
revealed.
_________________________________
Parent’s Signature
__________
Date
GROUP COUNSELING REFERRAL FORM- Teacher
Student's Name ___________________________________________
Grade_____ Date ________ Time________ Teacher ______________
Reason for Referral:

 Personal
 School
 Family
Name of Group Recommended for Student : _______________________
Reason for Referral: ________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
STUDENT REQUEST FOR GROUP COUNSELING
Name _______________________
ID#
Grade_____ Date ________ Parents Names
____________________
Reason for Referral:

 Personal
 School
 Family
Name of Group Requested: ____________________________________
Reason for Request: _________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
Counseling/Guidance Needs Assessment
Please indicate your current grade:
9th
10th
11th
12th
Please choose the 5 issues most important to you and/or our school.
Self-Esteem and SelfAwareness
Time Management/
Organization Skills
Suicide/Self-harm
Dating/Relationship issues
Job-seeking and job-keeping
skills/ Resume writing
Family/parent relations
Study Skills
Peer relationships/ Social
skills
Decision-making skills
School/ classroom behavior
Help for transfer students/
new students
Sexual Issues
Communication skills
Peer Pressure
Substance abuse
Anger Management
Career Planning/ Counseling
Problem Solving/ Coping
Skills
Goal Setting
Pregnancy/Teen
parenting
Other:____________________
Help with post-secondary
options, admissions, applications, and
financial aid
Other:________________________
Physical or sexual abuse or
neglect concerns
Academic Testing
Information and Explanation
Parent Separation
/Divorce/ Conflict
Other:________________________