Be Heard Consent Form

Child's Name

First Name

Last Name

Classroom Number

Teacher's Name

Relationship to the child

My Name

First Name

Last Name

All Caregivers are aware of the Childs involvement?

Yes

No

If not, please let us know why

I give consent for the Be Heard counsellor to speak to my child's teacher about my child's behavior at school

Yes

No

My child may attend the Be Heard Counseling service

Yes

No

Date

MM

DD

YYYY

If at any time you wish to withdraw your consent, please contact the General Manager by emailing referrals@beheard.org.nz