LOUISIANA DELTA COMMUNITY COLLEGE
STUDENT COUNSELING-DISABILITY SERVICES (SC-DS)
Client: Date: ______________________________________ ____________________
INFORMATION, DISCLOSURE, AND CONSENT FORM
WELCOME: Student Counseling-Disability Services welcomes you as a potential client. We believe it is important for
you to be informed about the nature of counseling, the policies and procedures governing the help you will receive here,
and your rights as a client. At the end of this statement, you will provide your signature indicating your general consent
to counseling.
COUNSELING: Counseling refers to the form of assistance that addresses various types of personal and family distress
such as depression, anxiety, adjustment difficulties, or relational conflicts. The goals of counseling range from the relief
of symptoms to significant life changes based on acquiring a better understanding of one’s personal, interpersonal, and
social circumstances. Counselors work within the standards and ethical guidelines of state licensing laws and
professional associations. Counseling is not provided through email or other electronic means.
COUNSELING PROCESS: Counseling begins with an intake process designed to evaluate your needs and difficulties and
to help you and the counselor make a decision about your engagement in the counseling process. If you or the
counselor believes someone else could better meet your needs, a referral will be initiated. Treatment is guided by a
treatment plan that both you and your counselor both agree to pursue. Counseling ends when the goals are met or
when you decide to terminate.
COUNSELING POLICIES AND PROCEDURES:
Your Rights as a Client: You have a right to be treated in a professional, respectful, competent, and ethical manner
consistent with the limits of state and federal law. These rights include informing you of the purposes, goals,
techniques, procedures, limitations, potential risks and benefits of services to be performed, and other pertinent
information. Clients have the right to expect confidentiality and to be provided with an explanation of its limitations, to
obtain clear information about their case records, to participate in the ongoing counseling plans, and to refuse any
recommended services and be advised of the consequences of such refusal. Counselors shall offer clients the freedom
to choose whether to enter into a counseling relationship and to determine which professional will provide counseling.
Confidentiality: Information given to your counselor will be kept strictly confidential and will not be revealed to other
persons without your written permission, except when mandated by state and federal statutes. By law, there are
circumstances by which a counselor must report information to the appropriate persons or agencies. These
circumstances include: 1) if you threaten grave, bodily harm to yourself or someone else; 2) if you reveal information
about child, elder, disabled or dependent adult or parental abuse; or 3) if ordered by a court of law. In all other
instances, your written permission is required before your counselor can reveal information about your treatment.
Appointments and Cancellations: All appointments are made with your counselor. If you are unable to keep a
scheduled appointment, please notify your counselor as soon as possible.
Emergency Contact: Counseling services are available for students in the event of an emergency. If necessary, Student
Counseling-Disability Services may serve as a referral agent to off-campus agencies such as hospitals, facilities, or private
practitioners that are deemed most appropriate. Should a referral occur, Student Counseling-Disability Services no
longer acts as the primary caregiver. In the event of an emergency on campus, call 318-345-9152 (Student Counseling-
Disability Services) or 318-345-9105 (Facilities Security Coordinator). If an emergency occurs off campus, you should call
911 or proceed to the nearest emergency room.
Clients Served by Others: If a client is receiving counseling services from another mental health professional, counselors,
with the client’s consent, shall inform the professional already involved and develop clear agreements to avoid
confusion and conflict for the client.
Cost of Services: Services received through this department are free of charge to currently enrolled students of
Louisiana Delta Community College. If it is determined the issue presented by the client is beyond our professional
capacity, we will assist in making an appropriate referral.
I have read the information contained in this Information, Disclosure and Consent Form and consent to treatment as
described in this form.
