Informed+Consent+-+Group+B

INFORMED CONSENT FOR TREATMENT


 * Introduction – ** The Southeastern Stokes Middle School Counseling Program exists to provide specific skills and learning opportunities in a positive, proactive, and preventive manner so that all students can succeed academically, vocationally, and socially (ASCA, 2005).

ABOUT THE COUNSELOR
Ø ** Credentials ** – Ø ** Licensing Regulations ** – All counselors are working toward licensure in School Counseling. Ø ** Supervisory Relationship **// – // Liberty University Faculty Member. Ø ** Ethical Guidelines ** – American Counseling Association (ACA). 5999 Stevenson Ave. Alexandria, VA 22304. (880) 347-6647. [|www.counseling.org]. American School Counseling Association (ASCA). 1101 King St., Suite 625, Alexandria, VA 22314. (800) 306-4722. [|www.schoolcounselor.org].
 * Stephen Hicks, ** B.A., working toward M.Ed in School Counseling. Experience: NewDirections Coordinator, Positive Behavior Support (PBS) Behavior Intervention Specialist.
 * Andre Carpenter **, B.A., M.Ed, working toward M.Ed in School Counseling. Experience: Classroom Teacher.
 * Jessie Green **, B.S. Childhood Studies, working toward M.Ed in School Counseling. Experience: Youth Advocate in a High School Setting, Case Manager (Americorp), Summer Youth Camp Counselor.
 * Jeff Chase **, B.A., working toward M.Ed in School Counseling. Experience: Boys/Girls Club Director/Counselor.
 * Tabitha Vandyke, ** R.B.A., working toward M.Ed in School Counseling. Experience: Elementary School Counselor.

ABOUT THE COUNSELING PROCESS
Ø ** Counseling Approach/theory- ** Southeastern Stokes Middle School Counseling Program utilizes a Reality/Choice and Solution-Focused Brief Therapy approach to counseling that focuses on present problems and provides specific interventions and a workable plan that is solution-focused. Ø ** Voluntary Participation ** – It is important to note that all students are voluntarily participating in the counseling process unless it is court ordered. Students can terminate counseling services at any time without being penalized due to the fact that participation is voluntary. Ø ** No Guarantees ** – Although services are provided and intervention strategies are put into place, this does not indicate or guarantee successful results. Ø ** Risks and Benefits Associated with Counseling ** – Participation in counseling can produce emotional discomfort due to the fact that students are challenged to engage new strategies and implement specific interventions. However, particular benefits can include improved academic and vocational achievement and social growth. Ø ** Length of Therapy and Termination ** – Typical counseling sessions will last a minimum of three sessions per semester possibly extending to six. Further sessions or referral will be determined at the discretion of the counselor. Ø ** Interruptions in Therapy ** – Counselors may experience personal emergencies that may prevent a counseling session to occur at a scheduled or specified time. If this occurs, the student will be notified by the counselor and another session will be scheduled. If this cannot occur, students will be notified by the administration of the cancellation. Ø ** Counselor involvement ****// – //** Counselors will provide personalized comprehensive counseling to each student involved in the counseling process. Counseling sessions are typically thirty minutes. If a student is unable to attend or is late arriving, a new appointment will be made.
 * Client Involvement ** – **The counseling process will require effort on the part of the counselor and the student. For the counseling experience to be successful, the student must be willing to work on things the counselor discusses in the sessions** **.** ** For sessions to be successful, students are encouraged to actively involve themselves in the process. **

= RIGHTS AND RESPONSIBILITIES OF THE CLIENT = Ø ** Confidentiality and Privilege **** – The student’s interactions with the counseling process including appointment history, the content of the sessions, participation, comments, progress, and counseling files are confidential. ** ** Confidential ** and privileged information will be released to a third party upon the written consent of the student. Ø ** Exceptions of Confidentiality and Privilege **// - // The exceptions to confidential and privileged information are the following: · If it is determined that the student is threatening physical harm to themselves or someone else, the counselor will take measures to protect the student or the other person. · If the student tells the counselor about an abusive situation, known or suspected, past or present, involving a child, elderly person, or disabled person, the counselor must take measures to file a report with the appropriate state agency. · If disclosure of the records is court-ordered.

Ø ** Counseling and Financial Records **// – // Counselors will establish a reasonable timeline for destroying student records or case notes and will adhere to state guidelines. According to ASCA (2005), “Suggested guidelines include shredding sole possession records when the student transitions to the next level, transfers to another school or graduates. Careful discretion and deliberation should be applied before destroying sole-possession records that may be needed by a court of law such as notes on child abuse, suicide, sexual harassment or violence (p.145). . Ø ** Disputes and Complaints ** – Disputes and complaints should be submitted to the counselor in writing and will be discussed in consultation with the administration. Ø ** Cancellation Policy ** – When possible, students should give at least a twenty-four hour notice when cancelling an appointment. = RESPONSIBILITIES OF THE COUNSELOR =

Ø ** Colleague Consultation ** – In order to provide students with the highest quality of service, the counselor may consult with other counseling professionals. If this should occur, the consultants are also ethically and legally bound to keep student information strictly confidential. Ø ** Tape Recording or Videotaping of Sessions ** – If it becomes necessary to tape or video a counseling session, it will be done only under written consent and they will be kept in a locked and secure place until use is determined to be terminated upon which they will be destroyed. Ø ** Dual Relationships ** – Counselors will avoid any contact with school personnel or students that may infringe upon the integrity of the counselor/student relationship. Contact with students outside of the counseling relationship will not exceed the boundaries of a professional relationship. Items and I understand the information that is contained in this document. I give my consent to the terms of this document and agree to enter into a counseling relationship.
 * Closing statement – ** I have read the information above with the counselor. The counselor discussed each of the

Student’s Signature __Date__ __ I give my consent for ___ __to enter into counseling sessions. 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__ _

Reference: American School Counseling Association (2005). //The ASCA National Model: A framework for// // school counseling programs // (2nd ed.). Alexandria, VA: Author.