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* 1. I would like to schedule a 15 minute check-in between my child and Mr. Michael on Wednesdays via Zoom.

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* 2. If yes, please add your student's name, grade, teacher, and an email address that I can send Zoom meeting requests to. This email will be used to join the Zoom meetings.

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* 3. I agree to the rules of confidentiality as provided below:

Informed Consent for School Counseling

I would like for my child to participate in individual meetings via Zoom virtually through Geist Montessori Academy with Mr. Michael, the school counselor. Individual counseling provides students with an opportunity to explore feelings, thoughts, and behaviors in a private, one-on-one session with a trusted adult (counselor).  

Confidentiality will be guarded within legal and ethical limits of the counseling profession. Limits to this confidentiality include a student being harmed, harming someone else, or plans to harm himself or herself. If the student shares any of these items, the counselor is required to break confidentiality by reaching out to the student's parents/guardians to ensure the safety of the student. Student safety is of upmost importance and is a top priority at GMA.

I have read and discussed the above statements with my child and would like my child to participate in counseling via Zoom on Wednesdays.

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