Nederland ISD Wellness Program Consent

Permission for 2023-2024 Wellness Program

Nederland ISD has an opportunity to provide Wellness Screenings for all high school students. These services will be provided by an outside agency, Samaritan Counseling Center of Southeast Texas. The screenings will provide information to students, guardians and school counselor regarding concerns that may be evident with your child’s mental health. Resource materials will be provided to student, guardian and school counselor after screenings are complete.

Student's Name:(Required)

By signing this consent form, I understand the following:

  • My student will participate in the Wellness Screening taking place during the school day as part of his/her education program.
  • Samaritan Counseling Center of Southeast Texas has permission to discuss my student's information (including screening scores, possible concerns, and services) with his or her high school counselor.
  • Nederland ISD has permission to share my contact information with Samaritan Counseling Center of Southeast Texas. This information will be used only to discuss possible concerns for my student and to set up services following the Wellness Screening.
  • Samaritan Counseling Center will send my student his/her Wellness Screening through his/her Nederland ISD email.
  • Data gathered will be used for research purposes, and that personal and identifying information will be kept confidential.
  • If counseling or follow-up services are recommended, my student will be paired with the appropriate professionals.
Parent Name(Required)
MM slash DD slash YYYY

If you would like more information regarding the Wellness Program, please visit www.sccset.org/wellnessprogram

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