Disclosure Statement And Consent For Counseling Services (Page 3 of 3) in pdf

Cancellation & Missed Appointments. Regular and consistent attendance at counseling appointments is

critical in order to benefit from the counseling process. Please make every effort to keep your appointments and an

attempt will be made to notify you in the event that a counselor has had to cancel your appointment.

Please initial in the line provided to acknowledge you have read and understand the Cancellation and Missed

Appointments Policy.

Cancellations: Your appointment times are reserved for you alone. If you need to cancel your scheduled

appointment for any reason, please do so 24-hours in advance so that we can make the time available to

someone else. If you cancel two consecutive sessions, you may be removed from your counselor's schedule.

Missed Appointments: Demand for services is high and at times we need to place students on a waiting list

due to limited appointment availability. If you fail to show up for two appointments, you may be removed

from your counselor's schedule so that another student can be seen. Once you are removed from your

counselor's schedule, you will need to call Counseling Services at 360-546-9238. If there are no openings

at that time, you may request to be placed on our waiting list for ongoing counseling.

Emergencies. If you experience a mental health emergency, including having an experience where you believe

you may harm yourself or someone else, please call 911 or the Clark County Crisis Line at 360-696-9560. This

resource is available 24 hours a day, seven days per week, including holidays.

Other policies. At any time you may refuse treatment, request a change in approach, or a change of your

counselor. Additionally, although it is very rare to do so, any member of the Counseling Services faculty and staff

has the right to end counseling for any circumstances determined to be relevant. These may include (but are not

limited to) issues with counselor safety, impairment, or if counseling is seen to be harmful. In these instances, you

will be provided with a list of referrals to other local providers, or transferred to another provider in Counseling

Services, depending on the circumstances.

If you have concerns about your counselor or the course of counseling, we encourage you to discuss them first with

your counselor. You may also talk about them with the Lead Psychologist. You may contact the licensing board of

the state, the Department of Health, or the ethics boards of the American Psychological Association. If you believe

your privacy rights have been violated you have the right to express complaints to the above offices and

organizations and to the Secretary of Health and Human Services.

If you have any questions about psychologist licensing, you may contact the Washington Department of Health at

1-800-525-0127; 101 Israel Road SE, Tumwater, WA 98501.

Treatment consent. I have been informed of the type of counseling I will receive from Counseling Services

counselors, the methods and techniques used; counselors’ education, training and experience; and the fees and

eligibility of counseling services. Furthermore, I have received this information in writing.

Please discuss any questions you may have about the counseling process, confidentiality, or any other concerns with

your counselor during your visit as soon as possible. To indicate your understanding and agreement to these

conditions, please print and sign your name in the space below.

____________________________________

Printed Name

____________________________________

_____________

Client’s Signature

Date

____________________________________

_____________

Therapist’s signature

Date

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Disclosure Statement And Consent For Counseling Services Page 3

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