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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