Youth Mentoring Consent Form

Counseling and Youth Mentoring Consent Form

The following information is needed so that your child can meet with either the counselor and/or youth mentor provided by the Shenandoah South Wellness Center.

Please check the services you would like your child to access:

works to build student confidence by helping students learn how to cope with stress, sadness, fear, grief and other feelings. Mentors work with kids one-on-one, and in group settings, to talk about the challenges they are facing. Wellness Center mentors are trained peer recovery specialists who have real-life experience and have implemented positive, healthy coping strategies to create happy, fulfilling lives.

helps students and families with mental health issues. Every student deserves the opportunity to experience personal success, both at home and school. With counselor support, family connections are improved and students learn coping skills and develop resilience so they can make healthy choices and decisions.

If the student is under 14 years of age and wants counseling a parent/guardian signature is required. Regardless of age, if your child wants youth mentoring, your signature is required. Children 14 and older may engage in counseling services without custodial consent.

Consent to Exchange Information

I consent to allowing the Shenandoah Community Health Clinic, Strength In Peers and Shenandoah County Public Schools to exchange information so it will be easier for them to coordinate services. This information includes, but is not limited to, health records; resource information; financial information; benefits/services needed; billing information; employment records; and eligibility for assistance programs and dates eligible.

I may withdraw my consent at any time by writing to any of the agencies. This will stop the listed agencies from sharing information after they know my consent has been withdrawn. I have the right to know what information about me has been shared, and why, when and with whom it was shared. If I ask, each agency will show me this information.

Consent to Data Collection

As part of a federal grant, Strength In Peers and the Shenandoah Community Health Clinic are conducting research to evaluate the effectiveness of having access to health services on school campuses. We request that students in grades 6-12 who receive counseling and mentoring services complete surveys about how they feel they are able to manage their academic learning and cope with stress. The benefit of completing these surveys is that service providers will be better able to provide you and your child support services. Complete confidentiality will be maintained. Your and your child’s responses will be stored in a secure online data system. Only aggregate (group) results (not individual responses) will be shared. Your name or your child’s name will not be made public. Participation is voluntary. If you choose not to participate, your child will still be eligible for services. You can stop or withdraw your consent at any time and it will not affect your ability to receive services.

Student Information

Please give us some brief information so we may best serve your child.

Counseling for the program is provided by the Shenandoah Community Health Clinic and mentoring services are provided by Strength In Peers. Questions about the program? Please visit shenwellnesscenter.com

*We apologize in advance for needing duplicate student information on our forms. Mentoring information is kept in a separate database from medical and dental information and thus goes to a different staff member for data entry. Thank you for your patience and understanding in this matter!

Thank you for your support!