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Mark Twain Union ESD |  E  6164.2  Instruction

Guidance/Counseling Services   

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Exhibit 1

Mark Twain Union Elementary School District

Counseling Referral Form

__ Mark Twain Elementary School __ Copperopolis Elementary School

Student:___________________________________________________________________

Teacher/Grade:__________________________ Date of Referral:__________________

Referred by: __ Student __ Parent __ Teacher __ Principal __ Other:_________________

Reason for referral to counseling:

Examples of behavior:

List a strength this student has:

THIS REFERRAL FORM MUST BE SIGNED BY THE PRINCIPAL

_________________________________________________________ _______________

Signature of Principal Date

CC: Principal, Counselor

Exhibit MARK TWAIN UNION ELEMENTARY SCHOOL DISTRICT

version: April 6, 2017 Angels Camp, California

Exhibit 2

6164.2

Guidance/Counseling Services

Mark Twain Union Elementary School District

Parent/Guardian Permission for Counseling Services

__ Mark Twain Elementary School __ Copperopolis Elementary School

Student:___________________________________________________________________

Teacher/Grade:__________________________ Referred by:_____________________

Parent/Guardian;

Mark Twain Union Elementary School District makes every effort to provide support services for your children which will assist in their successful academic, social and emotional growth. To promote these efforts, Mark Twain Union Elementary School District provides short-term individual and group counseling services on campus during the school day.

California law considers conversations between the student and the school counselor confidential. However; there are some exceptions to this confidentiality. If the school counselor has reason to believe that a student is being abused, neglected, or is a danger to themselves or others, the counselor has the legal, ethical and professional responsibility to report such concerns to the appropriate authorities.

Your child has been referred for individual, group or academic counseling or you as a parent/guardian have elected to seek counseling for you child. The counseling sessions will focus on social skills, self-esteem building, anger management, and/or problem solving skills. These sessions can be of benefit in helping students work through challenges in a non-threatening environment. Participation and involvement are strictly voluntary.

If you have any questions concerning the counseling program, please contact the school counselor or site principal.

__ I give my permission for my child to meet with the school counselor as needed.

I understand that permission is valid for the current school year, unless revoked.

__ I do not give my permission for my child to meet with the school counselor.

_________________________________________________________ _______________

Parent/Guardian Signature Date

CC: Parent, Principal, Counselor

Exhibit MARK TWAIN UNION ELEMENTARY SCHOOL DISTRICT

version: April 6, 2017 Angels Camp, California