COUNSELING SERVICES CLIENT CONSENT FORM
Counseling is offered as a confidential service to assist employees with trauma and stress such as: burnout, rape, victim of crime (both violent and non-violent), domestic abuse, traffic accidents, family or relationship problems, depression and anxiety. This will allow you to unpack your issues in a safe and professional environment. You will be provided practical tools to cope with distressing situations. Counseling and psychotherapy are beneficial, but as with any treatment, there are inherent risks. During counseling, you will have discussions about personal issues which may bring to the surface uncomfortable emotions such as anger, guilt, and sadness. The benefits of counseling can far outweigh any discomfort encountered during the process however. Some of the possible benefits are improved personal relationships, reduced feelings of emotional distress, and specific problem solving. We cannot guarantee these benefits, of course. It is our desire, however, to work with you to attain your personal goals for counseling and/or psychotherapy. The outcome of counseling is often positive; however, the level of satisfaction for any individual is not predictable. Your therapist is available to support you throughout the counseling process.CONFIDENTIALITY:
All interactions with Counseling Services, including scheduling of or attendance at appointments, content of your sessions, progress in counseling, and your records are confidential. No record of counseling is contained in any academic, educational, or job placement file. You may request in writing that the counseling staff release specific information about your counseling to persons you designate. EXCEPTIONS TO CONFIDENTIALITY:CLIENT/THERAPIST RELATIONSHIP:
You and your therapist have a professional relationship existing exclusively for therapeutic treatment. This relationship functions most effectively when it remains strictly professional and involves only the therapeutic aspect. Your Therapist can best serve your needs by focusing solely on therapy and avoiding any type of social or business relationship. Gifts are not appropriate, nor are any sort of trade of service for service.YOUR RIGHTS:
All individuals who are seeking and/or receiving services from any of our programs will be provided with effective, efficient services. As an individual using the service you have the following rights:REGULATIONS:
EMERGENCIES:
In the case of emergencies every effort will be made to provide you timeous care. Due to the turn-around time limitations particularly with non-English services it is recommended to call emergency services. You may dial 112 from a cellphone, or 10111 for police if you are a threat to yourself, or 10177 for ambulance services. Or request that someone close to you take you to a hospital for a 72hr holding period for psychiatric care.CONSENT TO TREATMENT:
By signing this form the employee agrees they have read, understood and agree to the terms and conditions within. You are voluntarily agreeing to receiving mental health assessment, treatment and services for yourself (or your child/spouse if said child is the client), and understand that treatment or services can be stopped at any time.