MCSD Consent for School-Based Therapy (2021-2022)


Your child has been referred by his/her/their counselor to receive school-based therapy services during the 2021-2022 school year.  By signing below you are consenting to services and agreeing to the following terms:

  • Students will be taken out of class time to be seen by the Center Associates therapist. The amount of time will vary from 20 to 50 minutes per session depending on individual need.
  • A parent/guardian needs to be present for all Initial Assessments and Annual Reassessments as they come due. If a parent/guardian is unable to attend then the student will not be seen for school-based therapy. 
  • Parent/guardian involvement beyond the Initial Assessment will be determined by the Center Associates therapist. If it is decided that a parent/guardian is not effectively engaged in the student’s treatment, then he/she/they may be discharged from continued school-based therapy.
  • Center Associates policy requires consent for services be obtained from both parents unless custodial rights have been terminated or it is proven that the student does not have any current, active involvement with a parent. The parent/guardian calling to schedule the initial school-based therapy appointment will be asked to provide contact information for the other parent(s).  This consent can be verbal and will be documented in the child’s Center Associates record. 
  • This referral is not a guarantee of ongoing therapy throughout the school year. There may be instances in which the Center Associates therapist determines the student is not appropriate for school-based therapy.  This information will be communicated with parents/guardians.
  • If applicable, the student’s insurance will be billed for all therapy appointments. The Marshalltown Community School District will be responsible for paying any copayments accrued for school-based therapy services only.
  • Any additional appointments (both therapy and medication management) occurring throughout the school year at the Center Associates office will be subject to Center Associates terms and conditions.

Any questions regarding school-based therapy services can be directed to your child’s school counselor, the Center Associates therapist assigned to your child’s school, or:

Kim Hagen, LISW

Clinical Director

Center Associates


I have read the information provided above and I understand the information contained in this form.
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Center Associates
9 N. 4th Ave.
Marshalltown, IA  50158