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Cross Connections Permission Form 2021-22

CLHS Health and Wellness Initiative

School Counseling Services for the 2021-22 school year through Cross Connections

Dear Parent/Guardian,

During the 2021-22 school year, CLHS has again arranged for a Biblical professional counselor from Cross Connections, Inc. to be available to our students on Mondays and Thursdays from 11:00 a.m. to 2:00 p.m. with the possibility of an additional weekday as needs arise. Students may meet with a counselor about any life issue. In the past, students who are experiencing trouble in school, conflict with peers, relationship problems, or just having a bad day have used this service. Your student may meet with the counselor by asking for an appointment through Student Services. If, after seeing your student twice and in the opinion of the professional counselor, it appears that your student would benefit from further counseling, you would be contacted directly at the phone number you provide on this permission form to discuss the possible need for a counseling referral and explore counseling options. Before any information disclosed in counseling would be shared with CLHS, the Cross Connections counselor who has met with your child would obtain your written permission.

While it is our hope that your student will have a successful academic year free from worry, fear, or difficulty, we know that adolescence can be a tumultuous time. There are times when personal or emotional issues interfere with a student’s ability to focus effectively on school work. Having a neutral adult with whom to talk can enable a student to see things more clearly and offer hope for dealing with even very difficult situations! Please prayerfully consider making this service available to your child. We encourage you to speak openly with your student about this service so that they understand how it works before classes begin. Having a readily available resource in mind when a crisis happens can often prevent the shame, fear, and distress that come with trying to handle things alone.

In order for your student to access these counseling services at school, the written permission of both parents and/or guardians must be on file in the Student Services office. There is also space on the form below for your student to sign. Including your student’s signature on this form also serves to inform him or her of this service at CLHS. In the event that your student is 18 years or older, his or her signature is the only signature required. By providing written permission, you are not requesting counseling services, but are making this an option which your student may choose to use if the need arises. If you to agree to allow your student the opportunity to participate in the counseling program at the school, please complete and sign the form below. This form may be turned in at the Cross Connections table at registration or to Student Services at any time throughout the school year.

Please complete the form below. Required fields marked with an asterisk *

We, the undersigned guardians, agree to allow our child to utilize the services of a Biblical professional counselor from Cross Connections, Inc. for the 2021-2022 school year. I understand that two sessions per semester are available to my child at no cost to me. If, in the opinion of the counselor, my child would benefit from ongoing counseling, please call me at the number below to discuss my child’s needs.

I acknowledge that CLHS staff members will be aware of my child’s referral for counseling through the Student Services Office; however, I understand that the Cross Connections counselor must obtain written permission from me before disclosing any information shared in counseling with the Guidance Office at CLHS or other CLHS staff.

Confirmation Email