DIABLO VALLEY COLLEGE INFORMED CONSENT STATEMENT
To all DVC students and potential students:
You must carefully read the entire "Terms & Conditions" and "Privacy Protection" statements
Below before using the Online Counseling Services at DVC. Please select "I Agree" at the bottom of the page if you
wish to schedule an online appointment.
TERMS & CONDITIONS Information about you is confidential. It is important that you supply the most current
information about yourself, your educational history, plans and career goals so that
online counselors may provide you with the most accurate information specific to your needs.
▪ Per the Family Rights and Privacy Acts, I hereby grant permission for DVC online counselors to release
academic information about myself during an Online Counseling appointment and/or workshop or group
session, via the ConexEd Meeting Center, which I understand to be encrypted and secured.
▪ When requesting an Online Counseling Appointment and while asking the online counselor questions, I
must authentically represent myself in all aspects.
▪ I am the student who will be attending the Online Counseling Appointment, and I will
o provide accurate personal information, educational history, and educational goals.
▪ I authorize the online counselor to provide me with information related to my academic records online
through the use of the Online Counseling website and the ConexEd powered Meeting Center.
▪ I authorize the online counselor to record my Online Counseling Appointment session for the sole purpose
of assisting me with my educational pursuits.
▪ I give permission to DVC counselors, relevant DVC personnel and ConexEd Meeting server personnel
(administrator) to, when necessary and for the sole purpose of improving the online meeting services,
have access to recorded information from an Online Counseling Appointment/Express-Walk-in between a
counselor and myself.
Privacy Protection I understand that when using the DVC online counseling services, I must protect my personal
information from others, therefore:
▪ I will provide an accurate and private email address.
▪ I understand that the Online Counseling program may email confirmation messages and notifications to
the address I provide.
▪ I understand that every time I request an Online Counseling Appointment my email address must be
accurate and private.
▪ I understand that if I choose to share an email account with another person, that person will have access
to my Meeting ID# and password, which may allow that person eventual access to my personal and
academic information.
▪ If I choose to share an email account, I release DVC Online Counseling Services and DVC from any liability
resulting from such action.
▪ I have read the above information in detail. I understand and agree to the Terms & Conditions and Privacy
Protection established for DVC Online Counseling.
PRINT NAME SIGNATURE
DATE ______________________________________
DVC Online Counseling Spring 2020 Pilot
Please review, sign and return this form to:
craniumappt@dvc.edu
