Permission for In-School Counseling Services ↘

This form gives the minor listed below permission to receive counseling/group services through YWCA Greater Austin. By signing this form, I agree that the minor will meet with a YWCA provider in person during school hours and/or at the YWCA office or virtually if requested. 

The YWCA Greater Austin makes every effort possible to protect and maintain your information confidential, however there are a few exceptions to this as it pertains to Federal, State, or local law, including HIPAA, and/or professional and ethical guidelines which mandate the following: 

Exceptions to confidentiality 

  • If we suspect individual poses a threat to themselves or someone else; 

  • If we suspect a minor/child, a person with disabilities, and/or an elderly person (65 yr. +) has been or is now in danger of being abused, neglected, or exploited; 

  • If an individual reports that they have been abused and/or exploited by any mental health provider; 

Other Exceptions 

  • If you (or your legal representative) request and give written consent for your records or case information to be released to yourself or a third party. This information can be released after consultation with the Clinical Supervisor or Clinical Director and after completing a YWCA Consent to Release of Information form.   

  • If your records are court-ordered by a judge; 

  • If the therapist discusses your situation with their supervisor, another professional within the agency, and/or in group supervision for training and consultation purposes only; 

We will make every effort to inform you ahead of time prior to disclosing any information and will work in consultation with designated school personnel to ensure proper communication. (see Working Agreement for more information on Confidentiality, HIPAA compliance, and fees if applicable). 

I understand YWCA policies concerning confidentiality and its limitations when working with a minor as listed above and understand the risks and the benefits of participation. I agree that information may be shared between YWCA and designated school personnel in collaboration and consultation which may include dates of service, information on the minor’s well-being, etc. 

I am the legal custodian/guardian of this minor, and there are no court orders in effect that would prohibit me from consenting to the treatment of this child. 

My signature below means that I understand and agree with all of the points above and understand that I have the right to revoke this authorization at any time.