Template for Level 3 Parent Permission Email

Dear ______________, 

As you know your student participated in the Universal Screen this morning. Following an initial review of the data, results indicate that your child would benefit from safety planning. 

This email is seeking your permission to share your child’s name, date of birth, grade and responses from the initial screener with a mental health professional from Clackamas County. 

If you would prefer to have your child be seen by a private mental health provider please respond that that is your intention. 

I, ___________________________ parent/guardian of ________________________ give permission for my child’s information to be shared. 

❏ Yes 

❏ No 

❏ I will make an appointment for my child with a private mental health provider.