Counseling Consent Form
School of Education
L.I.U. - C.W. Post Campus
Consent to Counseling - Practicum Consent Form:
________________________, 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
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
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.
Printed Name: _______________________________
Group Counseling Informed Consent Statement
Informed Consent Statement
(for group counseling)
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.
group leader signature