Form SSMH 1
Parent/Student Consent
The Department of Education and Training’s (DET) procedure, Supporting Students’ Mental Health and
Wellbeing outlines DET’s commitment to creating an inclusive learning environment that supports the
mental health and wellbeing of all students/children. This form records, in accordance with that
procedure, the consent of the student, and/or where necessary, their parent, to allow DET to determine
support options in the school environment for students with a suspected or confirmed mental health
difficulty.
Privacy Notice
DET is collecting personal information of the student named in this form, and/or their parent where necessary to allow DET to:

determine referral and support options for the student’s suspected mental health difficulty;

deliver quality support to your student within the school context; and

to discuss the student’s situation and information with external referral and support providers.
Any personal information collected will only be accessed by DET employees involved in supporting the student, and clinical care providers
and support agencies outside DET as agreed by the student and/or their parent. The personal information collected will not be given to any
other person or agency unless the student or, where appropriate, their parent, has given DET permission or DET is authorised or required
by law to do so.
The information on this form will be stored securely. If you wish to access or correct any of the personal information on this form or discuss
how it has been dealt with, please contact the student’s school in the first instance. If you have a concern or complaint about the way your
personal information has been collected, used, stored or disclosed, please also contact the student's school in the first instance.
Consent provided in this form will be considered valid for the duration of the school’s involvement in supporting the student with mental
health difficulties, unless this period is more than a year, in which case consent will be requested annually when the review of the Student
Plan, detailing social and emotional support needs takes place.
Student’s last name:
Date of birth:
Student’s first name:
Chronological age:
EQ ID number:
Gender:
School:
School Year level:
Parent:
Best contact phone:
Does student/parent require
an interpreter?
Yes
No
Has an interpreter been used to explain this
information?
Yes
No
In order to understand the educational impacts of the you/your child’s mental health difficulty and how the
school can make supportive adjustments to your/their education plan, information and advice must be
exchanged between certain DET staff and possibly clinical care providers and support agencies outside
DET.
Please indicate your consent with your signed initial if you agree to DET staff taking the following actions
for the purpose of ascertaining support options for you/your child’s suspected mental health difficulty.
Initial
here:
Allocation of a school case manager to coordinate the school support for you/your child.
School case manager
Name:_____________________________________Role:___________________________
Initial
here:
Referral to school guidance officer for the purpose of assisting the school to understand you/your
child’s mental health difficulties. In particular guidance officers can advise on adjustments to
support you/your child’s educational needs in the context of a mental health difficulty, and
coordinate school support when necessary. To inform their assessment of the you/your child’s
mental health difficulty, guidance officers may undertake class observations, discussions with
you/your child’s teachers, semi-structured interviews with you/your child, an interview with your/
the child’s parents, and possible psychoeducational assessments. If a formal psychoeducational
assessment is required, the school will provide you/your child with further information and
your/your parent’s consent will be requested on a separate form provided by the guidance officer.
Initial
Facilitation of referral to a clinical care provider if deemed necessary (if you/your child are not
Uncontrolled copy. Refer to the Department of Education and Training Policy and Procedure Register at
http://ppr.det.qld.gov.au to ensure you have the most current version of this document.
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Form SSMH 1
Parent/Student Consent
here:
currently supported by a clinical care provider), e.g. psychologist via a GP referral, direct referral
to Child and Youth Mental Health. Any referral will be discussed with you/your parent’s prior to
being made, and the form SSMH4: Student referral to Clinical Care Provider must be completed.
(See SSMH4 Student referral to Clinical Care Provider)
Initial
here:
Exchange of information, including diagnostic information from the clinical care provider, among
relevant school staff, such as you/your child’s case manager (named above), guidance officer,
teacher(s), principal and other departmental staff nominated by the school or you and/or your
child, for the purpose of providing supportive educational programs for you/your child.
Initial
here:
Recording of your/your child’s information relevant to their mental health difficulty on confidential
guidance files. Guidance files are managed by the school’s guidance officer and may include a
record of psychoeducational assessments, actions, reports and other material relevant to you/your
child’s education. These files are kept confidential and secured as per DET’s procedure Managing
the Departments Records.
Initial
here:
A Student Plan will be developed in OneSchool (an online system that assists in DET’s
requirement to collect, store and use information about students so that they may meet its duty of
care to all students and staff members and administer and plan for providing appropriate
education and support services to students). Any other confidential information pertaining to
your/your child’s mental health difficulty will be stored in OneSchool with an appropriate security
level (only relevant school personnel, and in some cases, only the Guidance Officer can access
this information) and an original signed hard copy (if available) will be held in the registered
guidance file in a secured location.
Please provide details of your/your child’s Clinical Care Provider or Support Agencies:
Agency/Professional
Contact person:
Contact details (phone/email)
I give consent for the recording, use and disclosure of my/my child’s personal
information as outlined above and I understand that any information gathered
in relation to my/my child’s mental health difficulty will be used by the school
exclusively for the purpose of understanding the educational impacts and how
the school may provide a safe, inclusive and supportive education program.
I understand that I can withdraw my consent at any time by notifying the school
principal in writing.
Student Name:
Date:
Signature:
Parent Name:
Date:
Signature:
Uncontrolled copy. Refer to the Department of Education and Training Policy and Procedure Register at
http://ppr.det.qld.gov.au to ensure you have the most current version of this document.
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Form SSMH 1
Parent/Student Consent
I have discussed with the student named in this form, and/or their parent, the
DET procedure Supporting Students’ Mental Health and Wellbeing, and that a
referral to and/or contact with a clinical care provider may be necessary for the
purpose of understanding the educational impacts of the student’s mental
health difficulty and how the school may respond effectively to provide a safe,
inclusive and supportive education program.
I am satisfied that the student/parent understands the purpose of the
information exchange referred to in this form and the recording of information
pertaining to the mental health difficulty of the student named in this form.
I understand that by signing below I accept my responsibility under DET’s
Supporting Students’ Mental Health and Wellbeing procedure.
Date:
Case Manager Name:
Signature:
AND if the Guidance Officer is not the Case Manager
I am satisfied that the student/parent has given informed consent to the school
recording, using and disclosing information about the student’s mental health
difficulty as described above. By signing this form I accept my responsibility
under DET’s procedure Supporting Students’ Mental Health and Wellbeing.
Date:
Guidance Officer Name:
Signature:
I have met/will meet with the student/student’s parent to discuss concerns and
negotiate reasonable educational adjustments. By signing this form I confirm
that I understand and accept my responsibility under DET procedure
Supporting Students’ Mental Health and Wellbeing.
Date:
Principal Name:
Signature:
The original signed version of this form is to remain in the student’s registered guidance file. Copies of this form
will be uploaded to OneSchool and provided to the parent and/or student.
Uncontrolled copy. Refer to the Department of Education and Training Policy and Procedure Register at
http://ppr.det.qld.gov.au to ensure you have the most current version of this document.
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