Microsoft Word - Informed Consent Form.docx

MAC GRADUATE HANDBOOK / INFORMED CONSENT FORM / 10-2016

INFORMED CONSENT FORM!

Client’s Name: _________________________________________ Date of Birth: _______________________

This informed consent document is intended to provide general information about the counseling services

provided by East Texas Baptist University Master of Arts in Counseling graduate student. This is a legal

document; please read it carefully before signing.

• Nature of Counseling: The type and extent of services that I/my child will receive will be determined

following an initial assessment and through discussion with me. I understand that there may be both

benefits and risks associated with participation in counseling. Counseling may improve ability to

relate to others, provide a clearer understanding of self, values, and goals, and an ability to deal with

everyday stress. I understand that counseling may also lead to unanticipated feelings and change,

which might have an unexpected impact on me/my child and my/my child’s relationships.

• Supervision: I understand that ____________________________________ (full legal name of

counselor-in-training):

o is currently completing his/her Master of Arts in Counseling degree at East Texas Baptist

University. In order to improve his/her skills, he/she is required to complete a practicum and two

internships.

o is currently under the direction of a site supervisor that is required to have a minimum of a master’s

degree; preferably in a counseling, or a related profession with relevant certifications and/or

licenses; a minimum of two years of pertinent professional experience; knowledge of ETBU’s

counseling program requirements, expectations, and evaluation procedures; and relevant

counseling supervision training.

o is currently supervised by a site supervisor at ____________________________________ (agency)

and an East Texas Baptist University faculty supervisor.

o will be on-site regularly until ______________ (date of last day on-site).

• Confidentiality: I understand that counselors maintain confidentiality in accordance with the ethical

guidelines and legal requirements of their profession. Effective counseling, however, sometimes

requires that confidential information be shared with other staff members, professors, or graduate

students who are training at East Texas Baptist University. When confidential information must be

shared, pseudonyms (false names) are used to protect the identity of the client. I understand that no

records or information about me will be released outside East Texas Baptist University without my

permission, except under certain circumstances: if I/my child present/presents a serious danger to self

or other person(s); if there is a suspicion or actual incident of child abuse or neglect; or a valid

subpoena is issued for my/my child’s records, or my/my child’s records are otherwise subject to a

court order or other legal process requiring disclosure.

Master of Arts in Clinical Mental Health Counseling

MAC GRADUATE HANDBOOK / INFORMED CONSENT FORM / 10-2016

• Video/Audio Recording of Counseling Sessions: I understand that the East Texas Baptist University

counselor-in-training routinely records counseling sessions. I understand that such recordings will

only be used for educational purposes and that the professors and/or students involved will respect and

protect the confidential nature of the sessions. It is understood that the recordings will be confidential

and only reviewed for supervision or educational purposes and will subsequently be erased by the

counselor-in-training within 90 days or at the end of the semester, whichever comes first. I understand

that because these are digital recordings, confidentiality is limited by the secureness of the technology

being used to store them. All efforts are made to keep recordings confidential but the possibility of

unforeseen technological events mean that confidentiality cannot be absolutely guaranteed. I

understand that all such recordings are property of the East Texas Baptist University Masters of Arts in

Counseling department.

If I have any questions regarding this consent form or about the services offered, I understand that I may

discuss them with my counselor-in-training or his/her site supervisor.

I have read and I understand the above. I understand that treatment may be stopped at any time and

there are no penalties for denying permission. I hereby consent to:

permit myself/my child to participate in the above described counseling activities

ONLY without recording it;

I permit audio or video recording of the counseling sessions.

Signatures Required:

________________________________________ ___________________________ ___________________

Client Full Legal Name (please print) Signature Date

________________________________________ ___________________________ ___________________

Parent/Guardian Full Legal Name (please print) Signature Date

(Required for clients under 14 years of age)

________________________________________ ___________________________ ___________________

Counselor-in-training Full Legal Name Signature Date

(please print)

________________________________________ ___________________________ ___________________

Site Supervisor Full Legal Name Signature Date

(please print)

• Client signature is needed if client is 18 or over.

• Either parent/guardian or client signature is needed if client is 14-17.

• Parent or legal guardian signature is needed if client is under 14.