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Jennifer Palese

Consent Forms
Current Counseling Resume
Personal Statement
Current News
Consent Forms
OCD Report
Resources for Counseling Students and Practitioners

Counseling Consent Forms

Counseling Consent Form

School of Education
School Counseling Program
L.I.U. - C.W. Post Campus
Brookeville, NY

Consent to Counseling - Practicum Consent Form:

I, ________________________, hereby authorize ______________________to provide

vocational or personal counseling and/or assessment upon ________________________.
(myself or name of subject)

I understand that my participation will remain confidential and my name and all
identifying information will be withheld by the counselor. I understand that my counselor
is working with me in part to fulfill a practicum/internship requirement for Long Island University.  As such, I am aware that our sessions will be audiotaped. At the end of
his/her practicum experience, my counselor will dispose of all taped sessions.
Participation is completely voluntary and I may decline these services at anytime. There
will be no financial costs to me for my participation in these services.
Questions about these services should be directed to the supervising faculty at L.I.U. C.W. Post

I have read and fully understand the consent form. I sign it freely and voluntarily. I have
been provided with a copy.


Signature: __________________________________

Printed Name: _______________________________
Group Counseling Informed Consent Statement
Informed Consent Statement
(for group counseling)

I,______________________________, acknowledge that group counseling is an activity that involves my being open, honest, and willing to participate with others as I strive, with them, to reach personal and group goals.  I may experience negative, as well as positive, feelings in this process.  I am entering this relationship voluntarily and pledge to work hard in the group in collaboration with the group leader and other members.



_________________________                           __________________________

              date                                                     group member signature

                                                                          group leader signature

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