EMERGENCY CONTACT INFORMATION
Confidentiality is an ethical standard that protects clients from the disclosure of information without their consent. Client contacts with the Counseling Office are confidential. We will not provide information about clients to friends, partners, faculty,
parents, employers or anyone else outside of the Counseling Office Staff. Information may be exchanged between the UA-PTC Counseling Office & Disability Office, without requiring client consent, when those offices are providing services for the
The Counseling Office will release information from counseling sessions to third parties only at the written request of the client. The “Authorization to Release Professional Information” form, signed by the client and a witness, will be used
for that purpose. The client must give informed consent and therefore his/her counselor will discuss, prior to release, the information to be released, to whom, and for what purpose. The client will also be advised about the possible effects of disclosure.
Disclaimer: At any point that you may become suicidal, I will provide you with resources and or contact your emergency contact listed with UA-PTC.
Typing your initials confirms that you acknowledge and understand the confidentiality policy and exceptions above.
I have voluntarily decided to seek personal counseling from the UA-PTC Counseling Office. I understand the following points about the treatment I will receive:
1. The treatment that I receive is considered confidential. I have been informed about the exceptions to confidentiality and presented with a full copy of the UA-PTC Counseling Office confidentiality policy.
2. Services are provided by staff members who are licensed counselors. Staff member credentials are kept on file and I may request to view those of my counselor.
3. The staff member who provides my personal counseling will offer treatment that is within the scope of his/her competence to provide.
4. Treatment will be based upon the particular issues, concerns, or problems which the staff member and I agree to work on.
5. Treatment goals are therapeutic in nature.
6. The treatment will consist of methods (strategies, techniques, and interventions) that are generally accepted in the mental health field as appropriate for the problems that I present. When there are limitations or foreseeable harm that could occur
with a specific method, the staff member will explain them to me.
7. The staff member believes the proposed treatment can improve my condition and enable me to achieve my goals but he/she cannot guarantee the results.
8. There is no direct charge or cost for treatment services.
9. I, as the client, will not be forced to continue with the proposed treatment. I can choose to discontinue my personal counseling at any time.
10. I have been presented with the “UA-PTC Counseling Office Client Information” sheet that defines other pertinent information about practices and procedures.
Upon consideration of the information presented to me, I authorize the staff member to provide me with personal counseling and to use the methods that he/she believes clinically appropriate. I make this decision to accept the proposed treatment knowingly,
voluntarily, and without coercion.
I understand that typing my full name in this box constitutes a legal signature confirming that I have voluntarily decided to seek personal counseling from the UA-PTC Counseling Office and I understand the above information.