Consent for Prevention and Intervention Services

Student Name:           	Student ID:                	School            	Grade:      

Sex: M/F:                   	DOB:                   	 Age:              	Referral Date:      

Dear Parents/Guardians:

As part of the Rockdale County Public Schools student support program, your child has the opportunity to work directly with individuals trained to assist your child with his or her behavioral and social/emotional needs through individual and/or group sessions. These services are designed to help your child achieve success in school. 

Prevention & Intervention Services:  The Prevention & Intervention program is designed to equip students with behavior management strategies that address a variety of concerns by enhancing problem-solving abilities, teaching decision making skills, learning how to manage conflict/change, and/or developing a positive self-concept.  Individual and/or small group sessions run between 30 to 45 minutes weekly. The meeting times will be scheduled with classroom teachers to avoid disruption to the academic day.  

The P&I Specialist assigned to your child’s school is: ___________________________________________
                                                                                                                       
We look forward to working with your child and creating a positive and rewarding experience for everyone.

Parent/Guardian Consent for P&I Services
____  	I give permission for my child to receive Prevention and Intervention Services in Rockdale County Public Schools.	
____  	I do not give permission for my child to receive Prevention and Intervention Services in Rockdale County Public Schools.	

Parent/Guardian Consent for Mentoring Services
____  	I give permission for my child to receive Mentor/Peer/Groups Services in Rockdale County Public Schools if available.	
____  	I do not give permission for my child to receive Mentor/Peer/Groups Services in Rockdale County Public Schools.	

Parent/Guardian Signature
By my signature below, I verify that I am, in fact, the current legal guardian for the above-named child.

Parent/Guardian signature_____________________________________________ Date: _________________________________

If you have any questions or concerns, please contact: ____________________________________________________________
               							(Name of the person making the referral/Phone/E-mail)

Return completed form to contact listed above.