Informed+Consent+-+Group+A

William Byrd High School offers a comprehensive guidance program for all students in grade 9-12. Through organized events, students may meet with their counselor in a variety of settings: classroom guidance presentations, testing/SOL checks, One Day Registration, and course credit checks. A large percentage of students have much more contact with counselors through individual or group meetings and career/college planning. ** We are here to serve our students and parents and welcome your visits and phone calls. **
 * INFORMED CONSENT FOR TREATMENT**

ABOUT THE COUNSELOR
Ø ** Credentials ** – Hayley Poland, M.A., Q.M.H.P., M.C.P.L. Kristen Merica, B.S., Q.M.H.P.  Elizabeth Gillis, B.S.  Kathryn Tucker Warren, B.S.   We have counselors that worked in the field as an intern at an inpatient facility for alcohol and substance abuse treatment, Assistant Director of Admissions for a University, School Assistance Program counselor in a middle school and Therapeutic Day Treatment Therapist in a high school. Ø ** Supervisory Relationship **// – // Marsha House is the School Counselor Coordinator at William Byrd High School, and can be reached at (540)890-3090. Ø ** Ethical Guidelines ** –The school counselors follow the American School Counselor Association Ethical Standards for School Counselors. You may obtain a copy from ASCA using the following contact information: [] (website) 1101 King Street, Suite 625 Alexandria, VA 22314 (703)683-ASCA (phone number)

ABOUT THE COUNSELING PROCESS
Ø ** Counseling Approach/theory- ** I work from many theoretical approaches, including but not limited to Narrative Therapy, Dialectical Behavioral Therapy, Cognitive Behavioral Therapy and Reality Therapy. I strive to meet the needs of every student by adapting my counseling approach to the student’s unique attributes. Ø ** Voluntary Participation ** –Participation in school counseling services are the choice of the student and may be revoked in writing at any time. If services are mandated by the court the school counselor is required to share information regarding participation in counseling. Ø ** No Guarantees ** – Benefits from school counseling services are not guaranteed. Ø ** Risks and Benefits Associated with Counseling ** – Students may find school counseling services to improve academic, career, and personal/social issues and concerns. However, school counseling services may provide no benefit or could heighten behaviors, issues and concerns discussed during counseling. Students may identify the need for more in depth services. Ø ** Length of Therapy and Termination ** – The school counselor will see the student for a maximum of six sessions on a particular issue before termination. At any time during those sessions, the student may be referred to more in depth services, and if issue has not been resolved within six sessions, the school counselor will make referral to outside agency as appropriate. Ø ** Interruptions in Therapy ** – The school counselor will make all reasonable efforts to inform the student of a cancelled appointment through a private message from the school staff. The student will inform the school counselor of a cancelled appointment under all reasonable circumstances by leaving a written message in designated area, leaving a voicemail on office phone, or discussing with school counselor prior to appointment. In the case of an emergency, the student should call 911**. ** Ø ** Counselor involvement **** //–// ** The counseling sessions will last no longer than thirty minutes except in crisis situations. The school counselor will provide a program that is comprehensive in scope, preventative in design and development in nature that will ensure every student receives maximum benefits from the program (American School Counselor Association, 2005). The school counselor will accept students up to five minutes late and the session will end at the original end time//.// Ø ** Client Involvement ** – The school counselor expects the student to be actively involved in counseling through participating with all assignments given and planned interventions. The school counselor expects the student to contribute to the counseling relationship by being open and honest.

= RIGHTS AND RESPONSIBILITIES OF THE CLIENT = Ø ** Confidentiality/Exceptions of Confidentiality ** – In accordance with the American School Counselors Association’s Ethical Standards (2005) the following standards will be upheld by the school counselors: a. Informs students of the purposes, goals, techniques and rules of procedure under which they may receive counseling at or before the time when the counseling relationship is entered. Disclosure notice includes the limits of confidentiality such as the possible necessity for consulting with other professionals, privileged communication, and legal or authoritative restraints. The meaning and limits of confidentiality are defined in developmentally appropriate terms to students. b. Keeps information confidential unless disclosure is required to prevent clear and imminent danger to the student or others or when legal requirements demand that confidential information be revealed. Counselors will consult with appropriate professionals when in doubt as to the validity of an exception. c. In absence of state legislation expressly forbidding disclosure, considers the ethical responsibility to provide information to an identified third party who, by his/her relationship with the student, is at a high risk of contracting a disease that is commonly known to be communicable and fatal. Disclosure requires satisfaction of all of the following conditions: • Student identifies partner or the partner is highly identifiable • Counselor recommends the student notify partner and refrain from further high-risk behavior • Student refuses • Counselor informs the student of the intent to notify the partner • Counselor seeks legal consultation as to the legalities of informing the partner

d. Requests of the court that disclosure not be required when the release of confidential information may potentially harm a student or the counseling relationship. e. Protects the confidentiality of students’ records and releases personal data in accordance with prescribed laws and school policies. Student information stored and transmitted electronically is treated with the same care as traditional student records. f. Protects the confidentiality of information received in the counseling relationship as specified by federal and state laws, written policies and applicable ethical standards. Such information is only to be revealed to others with the informed consent of the student, consistent with the counselor’s ethical obligation. g. Recognizes his/her primary obligation for confidentiality is to the student but balances that obligation with an understanding of the legal and inherent rights of parents/guardians to be the guiding voice in their children’s lives. · Other education professionals may have access to these records to enhance the academic, career, and personal/social achievements of the student. These professionals include, but are not limited to support staff, school social workers, school career center staff, school secretary Ø ** Privilege and exceptions to Privilege **// – // Privilege is not discussed due to school counselor not having privileged communication. Ø ** Counseling Records **// – // The school counseling files will be kept in locked and secured filing cabinets inside a locked room in the counseling department. They will be shredded after three years of the student withdrawing, graduating or leaving the school for any other reason. Indicate (list) how the records are kept and secured, for how long (check your state’s requirements), and how they will be discarded. Ø ** Disputes and Complaints ** –Concerns, disputes or complaints may be first addressed to the school counselor, then the William Byrd High School school counselor coordinator, Marsha House at (540)890-3090. A written complaint can be made to the principal, Dr. Richard Turner, William Byrd High School, 2902 Washington Avenue, Vinton, VA 24179. If this does not satisfy your compliant, you may contact  ASCA Ethics Committee, c/o the Executive Director, American School Counselor Association, 1101 King St., Suite 625, Alexandria, VA 22314. Indicate how you will resolve any disputes, and provide the necessary information for filing a complaint (licensing board, address, and phone number). = RESPONSIBILITIES OF THE COUNSELOR =

Ø ** Colleague Consultation ** – During counseling services, the school counselor may consult with other professionals in an effort to provide quality care. School counselor will make when appropriate to outside resources (ASCA Ethical Standards for School Counselors, 2004). Ø ** Dual Relationships ** – School counselors will maintain a professional relationship in all areas, including but not limited to: after school activities, community functions, religious activities, etc. In an effort to maintain confidentiality, the school counselor gives the student the choice of greeting the school counselor in public arenas. Client's Signature __________________________________________ Date ________________ Parent/Guardian's Signature __________________________________ Date ________________ (If client is a Minor) I have discussed and explained the above information with the client. Counselor's Signature _______________________________________ Date _______________ American School Counselor Association (2005). //The ASCA National Model: A Framework for// // School Counseling Programs, Second Edition. // Alexandria, VA: Author.
 * Closing statement – ** By signing below, I/we have been given the opportunity to ask questions, and I/we understand the information in this document. I/we consent for _____________________to receive School Counseling services. This document will expire_____________________. I understand that I can revoke this document at any time by submitting a written request to the school counseling department.