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Jennifer Palese

Consent Forms
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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
Campus.


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

Date:
______________

Signature: __________________________________

Printed Name: _______________________________
 
 
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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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