Informed+Consent-Group+B

Consent-Group B Group B Participants: Abbruzzi, J., Desaulniers, B., Elias, J., Montague, C., Perkins, M., Taylor, B.

INFORMED CONSENT FOR TREATMENT
 * Introduction – ** Liberty Elementary counseling department is dedicated to achieving academic excellence and meeting the needs of all students in order to achieve this goal, students may be referred for counseling. Students can also request counseling services. The goal of the counseling services is to help students make better decisions so they can function in school, at home, and in their community. There is no cost for counseling services through the school districts.

ABOUT THE COUNSELOR

 * ** Credentials ** – Counselors have completed a Master’s degree from an accredited university. Counselors have obtained mandatory and accredited trainings and contributes a cumulative years of experience of thirteen years. Counselors are also teacher certified in multiple areas.
 * ** Licensing Regulations ** – Licensure is obtained by the state of Virginia 1893 SE Bell Terrace, Lovely, Virginia 22222.
 * ** Supervisory Relationship **// – // First year counselors are supervised by an approved certified counselor. Supervisor: Jennifer Smith 555-345-6789.
 * ** Ethical Guidelines ** –ASCA American School Counselor Association, 1101 Kings Street Suite 625, Alexandria, VA 22314. Phone: 703-683-ASCA.

ABOUT THE COUNSELING PROCESS

 * ** Counseling Approach/theory- ** The counseling department operates from a cognitive-behavioral orientation and integrates 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.
 * ** Voluntary Participation ** – Participation in counseling is completely voluntarily and the student has the right to terminate counseling at anytime unless the court mandates counseling services.
 * ** No Guarantees ** – Counseling focuses on helping improve situations and circumstances however there are no guarantees that behaviors will improve or that the student’s problem will no longer exist. These services are not meant to take the place of psychological counseling or medication, which is not the responsibility of Liberty Elementary School.
 * ** Risks and Benefits Associated with Counseling ** – Counseling has the potential to provoke uncomfortable emotions. Every effort will be made to reduce negative effects. This department provides the opportunity to assists students improve academic levels, enhance interpersonal relationships and intrapersonal relationships.
 * ** Length of Therapy and Termination ** – The counselors will see students for a maximum of three ½ hour visits and at that time referral will be made if necessary.
 * ** Interruptions in Therapy ** – If the counselor is not available for a counseling session due to an emergency, the appointment will be re-scheduled. If in an emergency, an emergency number will be provided. If another counselor is available and the student chooses, they may choose to council with that counselor.
 * ** Counselor involvement ****// – //** The counselor will provide individual counseling for students as needed, however sessions will not last more than 30 minutes. Sessions will not extend more than 3 consecutive visits on the same subject.
 * ** Student Involvement ** – It is expected that the student will be open and honest about all information provided. It is also expected that the student will participate in the session. The focus is on helping the student find ways to handle the identified situation. This cannot be done if the student is not willing to be open, honest, and participate.

=RIGHTS AND RESPONSIBILITIES OF THE STUDENT=
 * ** 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:
 * ** Exceptions of Confidentiality and Privilege **// - // If a teacher or parent comes to me with information, they will need to give permission to discuss it with an administrator or student. In consultation with other professionals with expertise in an area relating to your case.
 * ** Counseling and Financial Records **// – // Counseling records will be kept in the counselor’s office in a locked cabinet.
 * ** Fees and Charges **// – // There are no additional fees; the counseling process is a service funded and provided by the school district.
 * If you are in danger
 * If someone else is in danger
 * Where mandated by law or if I am subpoenaed by the court.
 * Current or past physical, emotional, or sexual child or elder abuse is suspected or apparent.

=RESPONSIBILITIES OF THE COUNSELOR=


 * ** Colleague Consultation ** – It is vital that the counselor provides quality care to the student. In order to make this possible the counselor may consult with other professionals. When consultation occurs, the counselor will make every effort to insure that confidentiality is maintained and the students name will not be revealed.
 * ** Tape Recording or Videotaping of Sessions ** – For supervisory reasons, the counselor may need to record one or more sessions. Written consent would be requested prior to any video session or taping.
 * ** Dual Relationships ** – In order to maintain a professional relationship, the counselor will not address the student outside of the school. If the student initiates contact, the counselor will give a greeting. This is to protect the student’s confidentiality and to maintain a professional relationship. The counselor will not discuss any counseling information in a public location. The counselor will not accept personal gifts unless handcrafted by student. If the student 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. **

Student’s Signature __________________________________________ Date ________________

Parent/Guardian's Signature ___________________________________ Date ________________ (If student is a Minor)

I have discussed and explained the above information with the student.

Counselor's Signature _______________________________________ Date _______________