"Minor's Informed Consent
to Receive Counseling/Therapy
in School Settings" *

CHECKLIST FOR INITIAL STUDENT CONVERSATION
(This can then be placed in the file as documenttion of the discussion.)

Using clear language, geared to the child's level of understanding:

1. INFORM STUDENT ABOUT:
_____ Who are you, and why are you establishing a relationship with the student ?
_____ Nature of the relationship (e.g., including rules, roles, boundaries, as appropriate)
_____ Confidentiality and its Limits (i.e., when will you disclose, "no matter what?")
_____ Who will receive what information from you? (e.g., parents, teachers, others)
_____ Does the child have any control over the confidentiality rules?
_____ Possible outcomes of your contacts (e.g., evaluations, follow-ups, future services, etc.)

2. PROVIDE OPPORTUNITY FOR QUESTIONS
_____ Invite questions
_____ Clarify misunderstandings about ________________________________________

3. OBTAIN STUDENT ASSENT/CONSENT TO PARTICIPATE
_____ Make every effort to secure student's voluntary participation
_____ Inform student of outside contacts about him, as consented to by parents

4. OTHER (as required by local policies)
_____
_____
_____

*This must be tailored to fit the policies of your school setting.
For adolescents, also see, on this website, an Adolescent Informed Consent Form
that can be signed by both the adolescent and parent(s)

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