This form is intended to provide you with important information about the therapeutic relationship regarding you and your child’s rights and responsibilities. Please read this form carefully. Feel free to contact the Student Services Specialist (Ms Britney) with any questions you may have regarding this form, the therapeutic relationship, or your child’s progress during school hours. This is a consent form for your child to participate in short-term evidence-based and research backed crisis and therapeutic interventions at The Center for Creativity, Innovation, and Discovery (CCID) by “Ms Britney” and/or any of the Utah State University Social Work interns she is supervising namely:

Katlyn M., BSW program - Utah State University

Jacob (Jake) P., MSW program - Utah State University

School based mental health services are designed to teach skills to help students be more successful in their academic and social environments. Skills developed in these sessions often include coping strategies, stress management, problem solving, social skills, support services, and more. These sessions are not intended to replace non-school based therapy/counseling that you may arrange for the student and referrals for outside services may be recommended or suggested. This consent for mental health services is valid for one school year, student participation is voluntary and consent may be withdrawn at any time in writing.

Purpose

Utah’s 2025 Legislative Session Update: HB281 UpdateUtah Code 53G-9-901 & 53G-9-902

Parental Consent for In-School Mental Health Services

In accordance with Utah House Bill 281, Part 9 (2025), parental consent is required before a student may receive in-school mental health services.

Confidentiality Assurance

We understand that students are more likely to engage in open communication about their mental health when they feel their privacy is respected. Therefore, we are committed to maintaining the confidentiality of all mental health sessions. Notifications provided to parents will be designed to respect this confidentiality while keeping you informed. Confidentiality is a key feature of the therapeutic process. The information discussed in sessions will not be shared with anyone, except in situations required by law.

Additional exceptions to confidentiality required by law are as as described:

In the case that authorized personnel feel that your child is in danger of harming him/herself or others. Utah law mandates all adults as mandatory reporters and are required to take action and has a duty to inform. This may include informing the school administration, law enforcement agencies, 911, DCFS, or others as required by law. Every effort will be made to work with you and inform you first in such cases.

If instances of previously unreported sexual or physical abuse of a minor are brought to light. Utah State Law requires all adults to report this information to the proper authorities or assist you in making such a report. The school mental health personnel are Mandated Reporter, as are all adults in the State of Utah. The State of Utah designates a Mandatory Reporter as “any person who has reason to believe that a child has been subjected to abuse or neglect” (Utah Code Ann. §62A-4a-403)

If student records are court ordered, the school will attempt to contact you first. It is NOT appropriate for parents involved in divorce or custody cases to request a minor child’s mental health records as part of said case in order to maintain rapport and the therapeutic relationship between the minor child and school mental health personnel.

As part of a multi-tiered system of support (MTSS) within the parameters of FERPA

To maintain supervision requirements for licensure required by the Division of Professional Licensing (DOPL) as part of the Utah Department of Commerce, and the National Association of Social Workers (NASW)

Consent for Mental Health Services

I consent to my child receiving in-school mental health support sessions during the current school year.

Notification Preferences

To respect your privacy and your child's confidentiality, we offer the following notification preferences:

I prefer to receive a notification after each mental health session noting the the date and general nature of the session in accordance with the 2025 Utah HB 281

(NOTE: In Utah, the requirement to notify parents or guardians about a student's suicidal ideation, suicide threats, or suicidal self-injury is established under Utah Code § 53G‑9‑604. This statute mandates that schools notify a parent/guardian when their student threatens suicide (under § 53G‑9‑604(1)(a)) Additionally, the Utah State Board of Education’s administrative rule R277‑217 strengthens this obligation by listing “notifying parents of risk for suicide or self‑harm” as required educator conduct)

Restrictions

In accordance with the 2025 Utah HB 281 parents/guardians may restrict topics discussed during mental health sessions. List any topics you wish to restrict: