Informed Consent for Counseling Services & Consent to Release Records

Thank you for your interest in counseling services through Pencil and Pathways. Please review the following information carefully. This document outlines the nature, purpose, and scope of services provided, as well as your rights regarding confidentiality, access to records, and informed consent.

Explanation of Services

Counseling services are provided by Licensed Specialists in School Psychology (LSSPs) and may also include licensed psychological associates or trainees under appropriate supervision. These professionals work with students to support social, emotional, and behavioral functioning. Services will be delivered on school campuses through contracted agreements with schools or families. All providers are credentialed by the Texas State Board of Examiners of Psychologists.

Reason for Request of Services

Your child is being referred for counseling by school staff and/or a parent or guardian for one or more of the following reasons:

• Development of Social Skills

• Executive Functioning Support

• Behavioral Support

• Coping Strategies for Stress or Emotional Concerns

• Support with Adjustment or Interpersonal Difficulties

• Other Concerns Affecting Academic or Developmental Progress

Nature and Purpose of Services

Counseling sessions may be individual or group-based. A treatment plan will be created and shared with you before services begin. Sessions typically range from 45 to 60 minutes and will be scheduled in coordination with school or family availability. Progress will be shared through written communication or scheduled check-ins approximately every 6–8 weeks, or as needed. The overarching goal is to help the student meet their identified goals and improve emotional and behavioral functioning.

Confidentiality

We are committed to protecting your child’s privacy. Information shared during sessions is considered confidential and will not be shared without written consent, except as required or permitted by law (e.g., risk of harm to self or others, suspected abuse or neglect, or court order). See TSBEP Rule §465.12 and Chapter 611 of the Texas Health and Safety Code for additional details.

Information may be shared for consultation or supervision purposes only when necessary and only in a way that protects identifying details. If records include information about other individuals, such information will be redacted before release unless legally authorized.

Confidentiality limitations will be explained before counseling begins, and families will be informed of any changes in confidentiality status as they arise. A release of information form must be completed before communication with other providers or school staff occurs beyond the referral or routine coordination of services.

Supervision Disclosure

As a Licensed Psychological Associate (LPA) in the State of Texas, Kate Curran Mire is authorized to provide psychological services under the supervision of a Licensed Psychologist. She is currently completing the supervised experience required by the Texas State Board of Examiners of Psychologists to obtain independent practice authority as an LPA. Her supervising psychologist is:

Dr. Laura Guli, Ph.D., Licensed Psychologist (Texas License ##32973, 33145)

Dr. Guli provides ongoing clinical supervision, review of services, and professional oversight in accordance with state supervision requirements to ensure that services remain ethical, evidence-based, and of the highest professional standard.

In addition to her LPA licensure, Kate is also a Licensed Specialist in School Psychology (LSSP) with extensive experience in assessment, counseling, and consultation in school settings. Your child is in capable and experienced hands, and the supervision process adds an additional layer of professional review and accountability.

If you have any questions about qualifications or supervision arrangements, you are welcome to ask at any time.

Maintenance and Retention of Records

Records are maintained securely and in accordance with TSBEP Rule §465.22. This includes session notes, treatment plans, and any related documentation. Records will be stored in a manner that allows for timely access and retrieval. Unless otherwise required by law, records will be retained for at least seven (7) years after services end, or three (3) years after the client reaches the age of majority, whichever is longer.

If services are provided as part of a school contract, record retention and control may be governed by the school or district in accordance with state and federal laws.

Billing and Payment

Psychological services are provided at your child’s school. In accordance with Texas State Board of Examiners of Psychologists (TSBEP) rules and regulations, invoices will be issued to the school. Families will receive an estimate in advance and be copied on the invoice for transparency; however, payment is made directly to the school, not to the provider.

Consent for Services

Please indicate your consent for counseling services by completing the accompanying form. You may revoke consent at any time in writing. If the nature or scope of services changes significantly, new consent will be obtained. Your child’s participation in counseling is voluntary, and questions are always welcome.