INFORMED CONSENT
As a patient of Chadron Nebraska State College’s Counseling Center, your well-being is your
therapist’s top priority. Therapy is a relationship that works, in part, because of clearly defined
rights and responsibilities held by each person. Your therapist will use his or her professional
judgment to determine your appropriate course of therapy. This consent form helps to create the
safety to take risks and the support to become empowered to change. This form is also intended
to inform you about your rights as a patient, limitations to those rights, and your therapist’s
corresponding responsibilities.
The consent you provide herein will last the entire duration of your treatment unless you revoke
or modify your consent in writing. Do not sign this informed consent form unless you
completely understand and agree to all aspects. If you have any questions, please bring this form
back to your next session, so you and your therapist can go through this document in as much
detail as needed.
Risks and Benefits of Counseling
Counseling can be an effective tool in helping students cope with emotional, relational, and
developmental concerns. Counseling provides you with a safe environment to talk about your
concerns with a licensed professional trained to provide treatment. The therapeutic relationship is
unique because it is highly personal.
The benefits of counseling can include helping you develop coping skills, make behavioral
changes, reduce symptoms of mental health disorders, improve the quality of your life, learn to
manage anger and other emotions, and learn to live in the present, along with other advantages.
At the same time, counseling can also be a difficult process. In the course of your treatment, you
may experience difficult emotions or encounter unpleasant memories.
Ultimately, counseling is not an exact science and your therapist cannot guarantee any specific
therapeutic outcome. Your therapist will, however, use his or her professional judgment to
provide you with the best treatment possible.
Client Rights
As a client, you have the right to:
• Be treated with dignity and respect;
• Know your counselor’s qualifications and professional experience;
• Expect your counselor to keep your treatment confidential, except as noted further
herein;
• Ask questions about your treatment;
• Be informed about diagnoses, treatment philosophy, method, progress, and prognosis;
• Participate in decisions regarding your treatment;
• Obtain any assessment results and have them explained to you in a manner that you
understand;
• Refuse treatment methods or recommendations;
• End counseling at any time (though we ask that you please discuss your reason for
wanting to end counseling with your counselor);
• Request a second opinion, referral to another provider, or transfer to another College
counselor. Please call Colleen Brennan at (308) 432-6232 to request a transfer to another
College counselor).
Client Responsibility
You have responsibility to:
• Maintain your own personal health and safety;
• Take an active role in the counseling process, including honestly sharing your thoughts,
feelings, and concerns;
• Help plan and follow through with your therapeutic goals;
• Provide accurate information regarding past and present physical and psychological
problems (including hospitalizations, medications, and/or prior treatment);
• Provide notice of your desire to terminate the counseling relationship before entering
into a counseling relationship with another provider;
• Keep scheduled appointments (contact your counselor in advance to cancel and/or
reschedule appointments);
• Inform your counselor if, during the course of treatment, you become aware of any
conflicts of interest with another patient or College Counselor; and
• Promptly notify your counselor of any problems or concerns that render you unable to
participate in counseling.
Confidentiality
The College’s professional counselors recognize that confidentiality is essential to an effective
counseling relationship. With a few exceptions (noted below), everything you share throughout
your counseling treatment, including your identity, is confidential. Further, state and federal laws
establish certain rights to confidentiality.
Exceptions to patient confidentiality include, but are not limited to:
• Danger to self or others. If your counselor believes you intend to harm yourself or
someone else, your counselor is bound by laws and ethics to take steps to prevent that
harm from occurring.
• If you are a minor (under age 19), your parents or legal guardian(s) have access to your
records and discretion over them.
• If you disclose abuse or neglect of a child, an elderly person, or anyone who is similarly
defenseless, your counselor is required by law to report the abuse.
• If you are in a group counseling setting, your counselor must still maintain
confidentiality of the group. However, your counselor cannot guarantee that group
members will also maintain confidentiality.
• If a third party issues a lawful subpoena for your records, your counselor may be
legally obligated to disclose your records. Your counselor will ensure you are notified of
any subpoena and, as required by law, take steps to ensure the records are produced
subject to a protective order.
• If you have been referred for counseling by a College administrator, your counselor
will report your compliance with counseling to Senior Student Affairs Officer and the
CARE team.
• If your counselor or the College is required by law to disclose your records, your
counselor or the College may disclose information necessary to comply with such law.
Crisis Intervention
If you demonstrate that you are a danger to yourself or others, the College or your counselor may
need to take steps to place you under Emergency Protective Custody (EPC). If that occurs, your
counselor and another College employee will transport you to the Chadron Community
Hospital/Chadron Medical Clinic for treatment.
With your consent, the College will also contact your professors informing them that you will be
absent from class due to a medical issue and that you will contact them at a later date regarding
missed assignments. Once you physically return to campus, your counselor will follow up with
you regarding any other supportive measures.
Professional Consultation
From time to time, consistent with his or her ethical obligations, your counselor may consult
with other counselors about your treatment. Consultation helps your counselor ensure that he or
she is treating you appropriately. However, in the event your counselor becomes aware of a
conflict of interest, your counselor will appropriately limit or eliminate such consultation. All
counselors involved in the consultation are ethically bound to preserve confidentiality to the
same extent as your counselor.
Discharge Based on Professional Judgment
If your counselor determines that your needs go beyond his or her level of expertise, he or she
has an ethical obligation to refer you to another professional who can provide the care you need.
This might include, for example, a specialized counselor, medical care provider, psychologist, or
psychiatrist.
If, based on professional judgment, your counselor determines he or she cannot provide (or
continue to provide) treatment to you, your counselor may discontinue treatment and, as
appropriate, refer you to another provider. Referrals may be to another College counselor or to
an off-campus provider.
Authorization to Release Client Information
As the client, you may authorize release of your information whenever you choose. For
example, if you wish to have your counselor communicate with a professor or College
administrator (such as the Title IX Coordinator) on your behalf, you can sign a release of
information form and provide it to your counselor.
Please note that your counselor will only provide information as specifically authorized and
directed by you. Any additional or ongoing disclosures must be prompted by you or expressly
directed in writing on your release form.
Required Signature
I acknowledge that I have read and understand ALL of the above information and I am fully
aware of my rights and benefits and risks of counseling. I am also aware of limits to
confidentiality. If I have any questions or concerns about any of this information, I agree to
discuss these concerns with the counselor.
Signature – Student Date
Signature – Counselor Date
Revised March 2023
You may discuss any of the above with a counselor before
signing.
