Central Washington University, Student Medical and Counseling Clinic:
An Introduction to Counseling Services
Welcome! Our goal is to provide a safe place to examine and discuss important issues in your life. We believe that you have inner sources of strength, and in counseling we attempt to focus on those strengths to provide for healthy decisions and growth. Our primary philosophy is to respect your integrity and promote your welfare. Please initial each of the boxes below and sign on signature lines if you are in agreement with the statement.
1. All information discussedduring therapy is confidential. Information will only be released when you specifically grant permission or when required by law. In the event that the counselor determines that you may be harmful to yourself or someone else or if you confide that someone under 18 years of age, a dependent adult, or elderly person is the victim of neglect, or physical or sexual abuse, the counselor is required by law to report to the appropriate authorities, as necessary, to prevent further harm.
2. Information disclosed may be discussed with Clinic staff, including medical providers and/or CWU Case Manager when professional consultations are needed.
3. Be aware that there are some careers that may require you to release your medical and/or psychological information in order to be eligible for employment. If this is a concern for you please discuss it with your counselor.
4. If you are referred by a university employee that has concerns about you, your counselor may inform the staff/ faculty member that you have made contact with the Clinic and are, or are not, engaged in treatment.
5. The Counseling Clinic supports client rights.
You have the right:
A. To have accurate information concerning the operations of the Clinic. For example:
•your quarterly Student Medical & Counseling fee allows you to see a counselor for no additional charge; and
•the Clinic is designed to provide short-term counseling and if you need long-term counseling you may be referred to another community agency or counselor.
B. To refuse treatment/counseling.
C. To choose the counselor that best suits your needs.
D. To ask questions if you do not understand such things as the counseling plan, the counseling procedures and intervention, etc.
6. The demand for counseling services often exceeds the availability of appointments. It is your responsibility to let us know if you do not plan to keep a scheduled appointment. If you miss scheduled appointment it is your responsibility to reschedule an appointment as soon as possible. If you do not do this, your appointment slot may be given to another student and you may be placed on a wait list for services. Therefore, in order to best serve your needs we ask that you let us know 24 hours in advance if you cannot keep a scheduled appointment. If you do not cancel your appointment and fail to show for your scheduled appointment, your student account will be billed $25.00.
7. We understand that sometimes certain client-counselormatches don't work well. Sometimes talking about the differences will resolve them; at other times a change of counselor is needed. It is your responsibility to discuss your plans to stop counseling or your wish to change counselors with your counselor. We believe that this practice benefits you and your relationship with your counselor.
8. Students who elect to use e-mail as a mode of communication with the Clinic should be aware that e-mail is NOT confidential and may not receive a timely response by the counseling staff.
9. We hope to improve our services. We would like permission to use some of your information for a research study. We are conducting the study for the 2015-16 school year. As part of the research process, your information will be made anonymous. No identifying information will be released in the study results. Your participation means that you allow us to examine (for research purposes) the measures you will complete as part of our clinical protocol. Your participation is voluntary. Your choice to participate in our study will not affect your services. In addition, participating may not benefit you directly. Participation may benefit others, as we will use the information to improve our services. If you choose to participate, you can change your mind at any time by informing your counselor. You must be 18 or older to participate. This study has been reviewed by the CWU Human Subject Review Council (HSRC). You may contact the HSRC if you have questions about your rights as a participant or if you think you have been treated unfairly. The HSRC office number is (509) 963-3115. Please ask your counselor if you have any questions or if there is something you don’t understand. By signing below you give your permission to participate in the study conditions we described.
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10. As a training facility for doctoral and master-level interns, the Clinic uses video recordings as well as direct observation of sessions. Only those professional staff directly involved in the training process will have access to any identifying information about you. Furthermore, you will be informed if a session is being recorded or observed. All recordings will be deleted as soon as they are reviewed. By signing below you give your permission for video recording or direct observation.
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By signing below, I have acknowledged reading and understanding this form.
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Please let us know if you would like a copy of this form for your record.
For Staff Purposes Only:
I have reviewed this form with client.
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