STUDENT NAME ____________________________________________ DATE_____________________
MAILING ADDRESS___________________________________CITY___________STATE_____ZIP________
PHONE (HOME) _________________ (CELL)__________________ OK TO LEAVE A MESSAGE? Y N
BIRTHDATE_________________________ STUDENT ID # _____________________________________
Student Rights and Responsibilities: You have the right to:
Impartial access to treatment
Considerate, respectful care
Know the identity and professional status of your
Informed participation in decisions involving you
Know reason for any transfer or referral of care
Obtain access to your record includin
formation about diagnosis, treatment and
Personal and information privacy
Appointments, Cancellations and “no shows”: In general, the counseling offered in the COCC CAP Center is short term.
On average, students meet with a counselor 3-5 times. In some situations, more counseling is needed, but this will be
determined on a case-by-case basis. We reserve the right to discontinue counseling with a student due to not showing
for repeated appointments. Cancellation for scheduled appointments should be made at least 24 hours in advance by
calling the CAP Center at (541) 383-7200.
Legal Proceedings/Court Involvement: It is not our policy to testify at any judicial procedures on behalf of clients who
are engaged in adversarial issues. This includes legal proceedings involving marital, custody and /or visitation.
Rights to Privacy: The work we do here is confidential. Occasionally information from other persons or professionals is
useful in the treatment work. If that is acceptable, I will ask for your permission in writing and ask you to complete a
“Release of Information” form. Similarly, I will not seek or receive information from others who know you without first
receiving your permission. If there is specific information you believe would be helpful for me to know about,
particularly previous mental health treatment, please bring this to my attention as soon as possible.
Exceptions to Privacy: It is very important for you to know that some things, by law, cannot be kept private. Here are
the exceptions to your right to privacy:
1. Although it is not our policy to testify at any judicial procedures, if I am subpoenaed to testify in court, I may
have to give information about you without your permission. If this occurs, I will make an effort to contact you.
If you oppose release of information, a court may nevertheless require compliance with the subpoena.
2. I am a Licensed Clinical Social Worker. If I suspect a child or an elderly or disabled person is being abused, I am
legally required to report this to the authorities. LCSW’s are mandated reporters under Oregon Law.
3. If I learn of a client’s specific intent to bring harm to himself, herself, or to another person, or to commit an act
of violence, it is my responsibility to protect you and others. Under these circumstances, I reserve the right to
inform other family members, intended victims, or authorities as appropriate.
Student Signature Date
(By signing this form, I acknowledge that I have read and agree to the information contained herein)