PARENT/GUARDIAN CONSENT FOR PSYCHOLOGICAL SERVICES
Student Name:________________________________ Date: _________________________
School:______________________________________ Date of Birth(D/M/Y): ____________________
Provincial Student Number: ___________________ Grade: ________________________________
Parent’s/Guardian’s Names: _____________________ Phone: _______________________________
Service(s) recommended by the Program Planning Team:
___ Formal Psycho-Educational Assessment
___ Behavioral Consultation/Assessment
___ Counseling (Group/Individual)
___ General Consultation: __________
* please see the reverse for description of the above services
It is important for you and your child to understand that participation in the above activities is voluntary; your child
cannot be required to participate. You and/or your child also have the right to discontinue at any time. You have the right
to a copy of any reports/notes that are produced from the psychological service. If you decide to allow your child to
participate, your child’s report/note will be uploaded to a system-wide database that can be accessed by each
year’s teaching team, the school principal, Student Services regional staff, and senior AVRSB staff.
Conversations between the student and the psychologist are protected under confidentiality. The Canadian Code of
Ethics for Psychologist (2000) states that there are three exceptions to confidentiality. These are: when disclosure is
required to prevent clear imminent danger to the client or others, when legal requirements demand that confidential
material be revealed, and when the child is in need of protection.
Risks and Benefits of Psychological Service:
Benefits:
 Gather information about the student’s strengths and needs
 Offer recommendations to improve the student’s program plan
 May identify a specific diagnosis that could inform his/her program planning
Risks:
 May identify unexpected cognitive, information processing, or achievement deficits
 May identify a need for referral to outside agencies to explore other aspects of the student’s difficulties
Parent/Guardians please complete:
I/we consent for (name of student) _______________________ to receive the above indicated service. I understand
that specific school staff may be consulted, and the information about the referral will be placed in the student’s
Confidential folder. In the case of assessment, I understand that this information will be discussed at the Program
Planning Team meetings and will be used to program for my child; as well, a written report will be also be placed in
the student’s Confidential folder.
___________________________________
_____________________
Parent/Guardian Signature
Date
or
I/we do not consent for (name of student) ______________________ to receive the above indicated service.
___________________________________
Parent/Guardian Signature
_____________________
Date
Psycho-educational assessment protocols will not be released. Please note that your child will be seen by
the School Psychologist on a priority basis, not necessarily in order of referral.
If you have any questions or concerns, please contact ______________________________ at ___________________.
(School Psychologist)
(School Psychologist phone #)
* What is involved in a Psycho-educational assessment?
An individual psycho-educational assessment completed by a School Psychologist will include use of tests,
observations, and discussions with the student in a one-to-one situation at the school. Depending on the referral, the
assessment may include intellectual, development, academic and/or social-emotional tests and concerns. An
assessment may include a review of school history, classroom observations, as well as interviews/questionnaires with
the student, parent(s), or guardian(s), school personnel, and outside agencies such as family physicians and/or
community services. The parents/guardians will be asked to provide information about their child. Meetings with the
Program Planning Team (including parents/guardians) to review the results and clarify information will occur once the
assessment is completed. A written report will be completed by the School Psychologist and uploaded to a system-wide
database that can be accessed by relevant teaching staff and regional office specialists/consultants. The report can
also be provided to the parents/guardians.
* What is involved in counseling?
Counseling services can often help students to cope with life experiences that are impacting their ability to perform to
their potential. The goal of all counseling services is to promote student well-being and healthy communication between
the student and the significant individual’s in their lives. Conversations between the student and the psychologist are
protected under confidentiality. The Canadian Code of Ethics for Psychologist (2000) states that there are three
exceptions to confidentiality. These are: when disclosure is required to prevent clear imminent danger to the client or
others, when legal requirements demand that confidential material be revealed, and when the child is in need of
protection. Counseling notes outlining goals and progress will be completed by the School Psychologist and uploaded to
a system-wide database that can be accessed by relevant teaching staff and regional office specialists/consultants.
Counseling services at the school level are usually short-term.
* What is involved in a Behavioral Consultation/Assessment?
Often, the behavior of a student can have an impact on their ability to perform to their potential.
Many times, a referral to the School Psychologist for a behavioral consultation/assessment may be needed. A
consultation/assessment may include the following:, a review of school history, classroom observations,
interviews/questionnaires with the student, parent(s), or guardian(s), school personnel, and outside agencies (e.g.,
family physicians and/or community services), and emotional/behavioural testing. The parents/guardians will be asked
to provide information about their child. Meetings with the Program Planning Team (including parents/guardians) to
review the results and clarify information will occur once the assessment is completed. A written report/note will be
completed by the School Psychologist and uploaded to a system-wide database that can be accessed by relevant
teaching staff and regional office specialists/consultants. The report can also be provided to the parents/guardians.
* What is involved in a General Consultation?
Your child’s teachers may have noticed that your child is having difficulty learning in one or many areas.
A referral to the School Psychologist for a general consultation may be helpful as part of the program planning process.
A general consultation often involves a discussion with members of your child’s program planning team and a review of
your child’s student record. Your child may also be observed in the school setting. The school psychologist may provide
suggestions regarding strategies to assist your child’s learning.
The school psychologist may also suggest that the student receive assessment services in the future or recommend a
referral to another professional. However, a referral for formal assessment would not occur without parent consent.