Ka’au Program for Student Mental Health & Wellness
Iliahi 117/118 in TRIO Center
4303 Diamond Head Road
Honolulu, HI 96816
Ph: (808) 734-9585
kapkaau@hawaii.edu
Ka'au Program
INFORMED CONSENT FOR COUNSELING SERVICES
Eligibility, Appropriateness, and Referrals
Eligibility for personal counseling and case management with Ka’au Program for Student Mental Health & Wellness
(Ka’au Program) is based upon student’s status as an enrolled Kapi’olani Community College (KapCC) student. A
prospective or disqualified student may be eligible for educational counseling sessions.
Your First Appointment
During your first visit, you will spend time with a counselor discussing your immediate concerns. This will help both you
and your counselor decide how the Ka’au Program can best help you. These services may consist of individual
counseling, group counseling, psycho-educational classes, and/or an appointment with a consulting provider. In some
instances, you may be referred to an off-campus service for longer-term, intensive therapy or some other mental health
expertise not offered through the Ka’au Program.
Additional Appointments
Counseling sessions are scheduled for a maximum of 45 minutes. During an early visit with your counselor you both will
decide the goals of your work and the approximate length of the counseling contract. Because of the large number of
students requesting counseling, the Counseling Service generally provides short-term therapy.
Program Fees
There is no fee for Ka’au Program counseling services. If the Ka’au Program services do not meet your needs, you will be
referred to an off-campus professional. You are responsible for that professionals office fees.
Risks and Benefits
There are risks and benefits associated with counseling. Benefits of counseling typically include symptom relief, an
enhanced sense of well-being, an increased ability to cope with peer and family relationships and academic pressures.
You may also gain a better understanding of yourself which will assist in your personal development. On the other hand,
counseling often involves discussing unpleasant aspects of life, thus people in counseling may experience unpleasant
emotions like sadness, guilt, anger, frustration, and loneliness. It is important for you to discuss with your counselor any
questions or discomfort you have regarding the counseling process. Finally, people benefit from counseling in different
degrees. It is normal that some people find some types of counseling not helpful. You are encouraged to talk to your
counselor to find out what may work for you.
Confidentiality
My policies about confidentiality, as well as other information about your privacy rights, are fully described in a separate
document entitled Notice of Privacy Practices. You have been provided with a copy of that document and we have
discussed those issues. Please remember that you may reopen the conversation at any time during our work together.
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Discussions between a therapist and a client are confidential. No information will be released without the client’s
written consent unless mandated by law. There are possible exceptions to confidentiality explained in the Notice of
Privacy Practices. We may consult and exchange information with others on a care team to support your success and
campus’ safety.
Duty to Warn
In the event that the counselor reasonably believes that the student is a danger, physically or emotionally, to themselves
or another person, consent is given for the counselor to warn the person in danger and to contact any person in a
position to prevent harm to themselves or another person, including law enforcement and medical personnel. This
authorization shall expire upon the termination of services.
Cancellations and Not Showing-Up for an Appointment
A personal commitment is crucial to the success of counseling. 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, and do not call within 48 hours
to reschedule, your appointment time may be assigned to another student. A series of missed appointments may
necessitate referral to an off-campus provider.
Mutual Respect
Counseling is based on an underlying principle of deep respect for each student who comes for help. The Ka’au Program
is committed to this principle and expects you in turn to behave in a respectful manner with program counselors and
employees. Verbal abuse may trigger termination of services with a referral to the Dean of Students for follow-up. No
form of physical violence will be tolerated. Sexual relations between client and his/her therapist is against the law.
Racism, sexism and other forms of discrimination are not permitted. Being under the influence of any mind altering
substance is prohibited.
Professional Records
The laws and standards of mental health treatment require that records be kept. The Ka’au Program follows all state
and federal laws and professional standards. All records, either written and/or electronic form will be kept strictly
confidential per these laws and by professional ethical standards. I understand that Ka’au Program records are not a part
of my educational records and are part of my treatment records. The process to access your records are detailed in the
Notice of Privacy Practices.
Contacting Ka’au Program
Ka’au Program counselors are often not immediately available by telephone. We do not answer our phones when with
clients or are otherwise unavailable. At these times, you may leave a message on the confidential voice mail and your
call will be returned as soon as possible, but it may take a day or two for non-urgent matters. If, for any number of
unseen reasons, you do not hear from me or I am unable to reach you, and you feel you cannot wait for a return call or if
you feel unable to keep yourself safe, 1) Call ACCESS Line @(808) 832-3100 or the Crisis Text Line at 741741. If it is an
emergency, call 911 or go to the nearest emergency room.
Electronic Mail Communications
The confidentiality of electronic mail (e-mail) transmission cannot be guaranteed. For this reason, the Ka’au Program
discourages the sharing of compromising personal or clinical information through this medium. In addition, students
should be aware that Ka’au Program counselors may not always have immediate access to their email.
Social Networking Policy:
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Ka’au Program counselors will not accept friend or contact requestsfrom current or former client’s social networking
site (e.g., Facebook, LinkedIn, etc.). Adding current or former counselors as friends or contacts on social networking sites
can compromise confidentiality and privacy for both the student and the counselor.
OTHER RIGHTS
If you are unhappy with what is happening in therapy, I hope you will will talk with me so that I can respond to
your concerns. Such comments will be taken seriously and handled with care and respect. You may also
request that I refer you to another therapist and are free to end therapy at any time. You have the right to
considerate, safe and respectful care, without discrimination as to race, ethnicity, color, gender, sexual
orientation, age, religion, national origin, or source of payment. You have the right to ask questions about any
aspects of therapy and about my specific training and experience. You have the right to expect that I will not
have social or sexual relationships with clients or with former clients.
Additional Rights
I have the right to ask questions about any procedure(s) used during counseling. I can expect that if I wish, the
counselor will explain their approach and methods to me.
I have the right to decide not to receive therapeutic assistance from Ka’au Program. I can expect that if wish, my
counselor will provide you with the name(s) of other qualified professionals whose services I might prefer.
I have the right to end counseling sessions at any time without any moral or legal obligations. I will contact Ka’au
Program if I make such a decision without consulting with my counselor.
I have the right to file a complaint. If I believe my privacy has been violated, I may file a complaint with the Vice
Chancellor of Student Affairs office in writing.
If there are any concerns with Ka’au Program, please contact the Vice Chancellor of Student Affairs,
Dr. No’eau Keopuhiwa at (808) 734-9523 or noeau.keopuhiwa@hawaii.edu
CONSENT TO PSYCHOTHERAPY
Your signature below indicates that you have read this Agreement and the Notice of Privacy Practices and
agree to their terms.
I certify that I have read, understand, and agree to abide by the information outlined above regarding my eligibility and
use of Kapi’olani Community College, Ka’au Program for Student Mental Health & Wellness counseling services. I hereby
give my consent to authorize Kapi’olani Community College, Kaau Program for Student Mental Health & Wellness
counselor to evaluate, counsel, and/or refer me to others as needed.
I have had the opportunity to discuss any questions regarding the above information.
Student Signature: ________________________________________________ Date: ____________________
Counselor Signature: ______________________________________________ Date: ____________________
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