CONSENT FOR SERVICE AGREEMENT
Counseling services are provided to students free of cost. Services provided include: Consultation, brief short term
intervention, education, crisis intervention, personal counseling/therapy, and referrals to both in-network and community
providers. The goal of counseling services is to:
- Assist and enable students in personal and career development so that each student has the opportunity to reach
his/her ultimate potential
- Empower and advocate for the student's personal and educational development through short-term counseling and
education
- Help students develop effective solutions and decision making capabilities in order to return to their normal
functioning as soon as possible
In-network providers: This counseling office works within a network of ND colleges in which referrals may be made to
other professionals. The diverse backgrounds, specialties, and separate professional licenses held by the consulting
professionals ensure a multi-disciplinary assessment of the student. The result is a fully comprehensive treatment plan. If
appropriate, a student at this local campus may be connected to these in-network providers via telephone and/or tele-
medicine. If tele-med services will be used, an additional consent form must be signed by the student.
STATEMENT OF CONFIDENTIALITY
Counseling is confidential. Information obtained during counseling sessions will not be disclosed to any outside persons
or agencies without the student’s written permission. Permission may be given by signing “Release of Information” filled
out by the counselor and the student. The student may choose to not sign any Releases of Information. Releases of
information are not required for communication between in-network providers.
Exceptions to confidentiality: A counselor is required by law and professional ethics to disclose confidential information
under the following general conditions:
1. You are a danger to yourself or others. The counselor has the duty to inform appropriate persons if there is a clear
and imminent danger to either the client or to another person. In these cases, the counselor will inform the client
that involved persons will be contacted.
2. The counselor is required by law to immediately report known or suspected child and/or elder abused/neglect to
the appropriate social service agency.
3. Certain civil or criminal proceedings may require a counselor to testify in a court of law or to provide pertinent
counselor records to the court if subpoenaed by the court of law.
Records: Counseling Services documentation never becomes a part of the permanent educational record.
Cancellations and not showing-up for an appointment: Please keep all of your scheduled appointments. If you need to
cancel, do so as far in advance as possible. If you “no-show” for an appointment, your appointment time may be assigned
to another student. Three consecutive “no-shows” may result in a referral to an off campus provider.
CONSENT TO TREATMENT:
1. I am voluntarily seeking assistance.
2. I have reviewed the expectations of the counseling process with the counselor
3. I understand that I have the right to terminate counseling at my discretion
4. I have read and understand the Statement of Confidentiality printed above.
___________________________ ________________________ _____________
Student Signature Please Print Name Date
___________________ ____________________ __________________ _________________
Student Date of Birth Phone Number Email Address Current School
