Telephone: 227 7144 Antelope Street

Fax: 227 4678 Belize City, Belize C.A.

Parent/Guardian Informed Consent Form

Introduction

Parent/Guardian: This form is intended to provide you with important information about the
counseling relationship and you and your childs rights and responsibilities. Please read the form
carefully. Feel free to contact the school counselor with any questions that you may have regarding
this form.

Gwen Lizarraga High School is a public school governed by the government of Belize, committed to
providing quality education to its students. It provides a relevant and well-rounded curriculum in
a co-educational and non-discriminatory environment to facilitate students in their intellectual,
physical, ethical, spiritual and emotional growth. In an effort to achieve this goal,
parents/guardians or 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 to students.

Background

The counselor responsible for the development of our children is Ms. Cloudette Williams, who has
a Masters Degree in Mental Health counseling. Ms. Williams has been employed by Gwen
Lizarraga High School for ten years and has taught Office Administration, Information Technology,
and Electronic Document Preparation & Management to first through forth form. She also has five
years teaching experience in the elementary level. She completed her internship at Raynham High
School in Bridgewater, Massachusetts during the year 2016-2017. Her extensive work in the
classroom plus knowledge and experience gained in the field as a counselor gives her the
experience and knowledge needed in order to help the students of this institution.
Provisions of Service:

Counseling service at the Gwen Lizarraga High School consists of classroom guidance through

personal development classes, intake assessment, short-term individual counseling, crisis

intervention, group counseling and referrals as needed. The counselor will provide weekly sessions

with students in their first year once a week and discuss such topics as: personal hygiene, bullying,

body safety, careers, and skills for academic success throughout the academic year. Each classroom

guided session lasts for forty minutes and a variety of techniques are used such as games, songs, art,

stories and role play to help students grasp the concepts. Some counseling sessions may also be

recorded for further consultation with the counselors supervisor. Individual counseling is offered

to students first through fourth year who are referred by teachers or administration or who seek

services on their own. When students are referred or seek individual counseling it is the policy of

the school that written permission is obtained by the parent/guardian. Services on an individual

basis include: (1) An Intake Assessment (students basic information and reason for requesting

counseling services is discussed) (2) Short- term individual counseling using Solution Focused Brief

Therapy (a goal oriented technique that targets a desired outcome, its focus is on the present and

future circumstances and desires as opposed to just past experiences) (3) referrals as needed to

specialized agencies.

Confidentiality:

Confidentiality is a key feature of the counseling experience. 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 her supervisor or other counselor to
seek consultation, with parents/guardians, the childs 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:

i. Presenting a serious danger to self or another person

 ii. Evidence or disclosure of abuse (physically or sexually) or neglect
iii. Threats to school security
iv. Criminal or delinquency proceedings are pending.
v. If counseling records are court ordered, the school counselor will attempt to contact you
first. However, he/she must comply with the court.

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.

In regards to counseling with minors, children under the age of 18 years, although the information
shared during a counseling meeting is confidential, parents/guardians have a right to be informed
of their childs general progress.

Risk:

By signing this Informed Consent Form you are indicating that you understand that while school

counseling services are aimed at more effective education and socialization for your child within

the school and community, there may be both risks and benefits with participation in counseling.

Counseling may greatly improve your childs ability to relate to others, provide a clearer

understanding of him/herself, along with values, goals and the ability to deal with everyday stress.

On the contrary, counseling may lead to unanticipated feelings and change, which might have an

unexpected impact on your child and his/her relationships.

These services are not intended as a substitute for psychological counseling, diagnosis or
medication and is not the responsibility of the school. By signing you are also indicating that you
agree that it is your responsibility to determine whether additional or different services are
necessary and whether to seek them for your child.

I have read this document with sufficient time to be sure that I considered it carefully. I asked
questions that I needed for more clarification and better understanding. I understand the limits to
confidentiality required by law. I understand my rights and responsibilities as a parent/guardian
as well as my childs and my therapist's responsibilities to me.
Contact

I understand that I am entitled to ask questions and receive information about methods or
techniques used by the counselor and the length of counseling. I am free to seek a second opinion or
end counseling at any time.

I give permission for my child to receive individual and/or group counseling services while
attending Gwen Lizarraga High School. (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 understand that I may request counseling services at a later date if needed.

I, _________________________________, am the legal parent/guardian of _______________________________________.

I have read, understand, and agree to the terms of the School Counseling Informed Consent.

Custodial Parent/Guardian Signature__________________________________Date_____________________________

Phone: Daytime phone _________________________________ Cell phone_______________________________________

Email______________________________________________________