Informed+Consent+-+Group+D


 * INFORMED CONSENT FOR TREATMENT**

ABOUT THE COUNSELOR **
 * I am currently employed at Union County Elementary School as a School Counselor. I provide individual and group counseling for children. I support the school's mission to promote our students' academic growth and achievement. **

Ø ** Credentials ** – I have experience as a group leader for a support group for children of separated and divorced. I am a school counselor candidate in the Liberty University, Lynchburg, VA M.Ed. School Counselor program. I am a member of Christian Educators Association International (CEAI), the American School Counselor Association (ASCA), The North Carolina School Counselor Association (NCSCA), the ASCD (formerly the Association for Supervision and Curriculum Development), and the Council for Exceptional Children (CEC). Ø ** Licensing Regulations ** – I have passed the licensure exam as per the guidelines of the NC Department of Public Instruction and am pursuing licensing. Ø ** Supervisory Relationship **// – // As a school counselor intern, I am under the supervision of a licensed school counselor who may observe counseling sessions periodically. Ø ** Ethical Guidelines ** – I follow the counseling guidelines contained in the American School Counselor Association Code of Ethics. The ethical guidelines can be located at the following website: http://www.schoolcounselor.org/files/ethical%20standards.pdf

ABOUT THE COUNSELING PROCESS
Ø ** Counseling Approach/theory- ** I operate from a cognitive-behavioral orientation and integrate the family systems theory and choice theory. The cognitive-behavioral view is that an individual’s thinking produces feelings that produce behaviors. Therefore, an individual can learn new behaviors and modify existing behaviors through an awareness of their own self-talk and irrational thoughts. The family systems theory utilizes fun activities to help the student become more aware of his/her thought process. Ø ** Voluntary Participation ** –Participation in counseling is completely voluntarily and you have the right to terminate counseling at anytime unless the court mandates counseling services. Ø ** No Guarantees ** – Counseling focuses on helping improve situations and circumstances however there are no guarantees that behaviors will improve or that the client’s problem will no longer exist. Ø ** Risks and Benefits Associated with Counseling: ** Ø Counseling has the potential to provoke uncomfortable emotions. Every effort will be made to reduce negative effects. Ø Counseling provides the opportunity to assists students improve academic levels, enhance interpersonal relationships and intrapersonal relationships. Ø ** Length of Therapy and Termination ** – I will see you for a maximum of three ½ hour visits and at that time referral will be made if necessary. Ø ** Interruptions in Therapy ** – If I am not available for a counseling session due to an emergency, our appointment will be re-scheduled. If another counselor is available and you may choose to council with that counselor. If in an emergency, call 911 after office hours. Ø ** Counselor involvement ****// – //** I will provide individual counseling for clients as needed, however sessions will not last more than 30 minutes. Sessions will not extend more than 5 visits in a row. Ø ** Client Involvement ** – It is expected that the client will be open and honest about all information provided. It is also expected that the client will participate in the session. The focus is on helping the client find ways to handle the identified situation. This cannot be done if the client is not willing to be open, honest, and participate. = RIGHTS AND RESPONSIBILITIES OF THE CLIENT =

Ø ** Confidentiality and Privilege ** –I follow the counseling guidelines contained in the American School Counselor Association Code of Ethics. This means I will keep the information you share with me confidential. Your written permission is required to share it or under the following conditions: Ø If you are in danger Ø If someone else is in danger Ø Where mandated by law or if I am subpoenaed by the court. Ø Current or past physical, emotional, or sexual child or elder abuse is suspected or apparent. Ø ** Exceptions of Confidentiality and Privilege **// – // Ø If a teacher or parent comes to me with information, they will need to give permission to discuss it with an administrator or student. Ø In consultation with other professionals with expertise in an area relating to your case. Ø ** Counseling Records **// – // Counseling records will be kept in my office in a locked cabinet for seven years and then will be shredded upon reaching the seven years. If a student transfers, the records will be kept for a total of three years and then documents will be shredded. Ø ** Fees and Charges ** // – // There are no additional fees; the counseling process is a service funded and provided by the school district.

= RESPONSIBILITIES OF THE COUNSELOR =

Ø ** Colleague Consultation ** – It is vital that I provide quality care to the client. In order to make this possible I may consult with other professionals. When consultation occurs, I will make every effort to insure that confidentiality is maintained and the client’s name will not be revealed. Ø ** Tape Recording or Videotaping of Sessions ** – For supervisory reasons, I may need to record one or more sessions. Written consent would be requested prior to any video session or taping. Ø ** Dual Relationships ** – In order to maintain a professional relationship, I will not address the client outside of the school. If the client initiates contact, I will say hello. This is to protect client’s confidentiality and to maintain a professional relationship. At school, the client may say hello as well as I may say hello, but I will not discuss any counseling information in a public location. I do not accept personal gifts. If the client has a desire to give a gift, he or she may give something for the office.


 * I have read the information above with the counselor. The counselor discussed each of the above items with me 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. **

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___

References

American School Counselor Association (2005). //The ASCA National Model: A Framework for//

//School Counseling Programs, Second Edition.// Alexandria, VA: Author.

Szapkiw, A.J.R. (2010). //Informed Consent Template// [Template]. Retrieved from Liberty University website: [|www.liberty.edu].