Counseling Appointment Request

As a student within Monroe College, you have access to mental health counseling services, upon request. Please provide your name and contact information and read the following: I hereby authorize a Licensed Psychotherapist within Monroe College to provide counseling and/or psychotherapy services, as explained to me. I understand that, while this therapy may be beneficial, as with any treatment, there are inherent risks. During counseling, I will discuss personal issues that may bring up uncomfortable emotions such as anger, guilt, and sadness. The benefits of counseling can far outweigh this discomfort and can lead to benefits, such as improved personal relationships and reduced feelings of emotional distress. I acknowledge, however, that no warranty or guarantee can be made as to the results of therapy.

CONFIDENTIALITY: I understand that discussions between myself and my therapist, as well as any records, are confidential with the exceptions noted below. No information will be released without my written consent unless mandated by law. If I have any questions regarding confidentiality, I will bring them to the attention of my therapist. By signing this Information and Consent Form, I am giving consent to the assigned therapist to share confidential information with all persons mandated by law. I am also releasing and holding harmless the undersigned therapist from any departure from my right of confidentiality that may result.

DUTY TO WARN/DUTY TO PROTECT: I understand that my therapist is a mandated reporter and by law is obligated to disclose any information related to the harm or intent to harm a minor or vulnerable person as stated by law. Additionally, if my therapist believes that I am in physical or emotional danger, or I am a danger to another human being, I understand that my therapist is required by law to contact medical or law enforcement personnel to prevent harm to me or another person and may contact the person in danger.

CONSENT TO TREATMENT: Counseling and/or psychotherapy as stated, including the possible risks, complications, options, and expectations, have been explained to me or my representative, and consent for treatment is thus given as noted by signature. I am voluntarily agreeing to receive a mental health assessment, treatment and services for me, and I understand that I may stop such treatment or services at any time.