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INFORMED CONSENT FOR STUDENT COUNSELING SERVICES
Welcome to the SUNY Potsdam College Counseling Center. This document contains important information
about our professional counseling services and business policies. Please read it carefully.
COUNSELING SERVICES
The Service. The SUNY Potsdam College Counseling Center provides a short-term, solution focused
counseling service. Your Counselor may consult with other licensed professionals within the Counseling Center
or Student Health Services with the consent provided in this document.
Risks and Benefits. Counseling can have risks and benefits. Therapy often involves discussing unpleasant
aspects of your life, and you may experience uncomfortable feelings like sadness, guilt, anger, frustration and
loneliness. However, counseling has also been shown to have benefits for people who go through it.
Treatment Plan. Your first appointment is for information gathering to evaluate your needs and
determine if the treatment required for your concerns can be addressed at the Counseling Center. Based
on this consultation evaluation, your Counselor will be able to offer you some first impressions of what your
work together will include, begin to develop goals and work towards collaborative plan of treatment to follow
if you decide to continue with therapy.
Session Limits. The College Counseling Center utilizes the brief, solution-focused model due to the time
constraints of the semesters. In order to allow a greater number of students to access services we see students
every other week as long as student is engaged in therapy. As sessions each semester are limited, it is
important you and your counselor establish goals to allow you to gain the most from your time at the College
Counseling Center. Frequent crisis appointments often indicate the need for a higher level of care beyond
the scope of practice of the College Counseling Center.
Alternatives. If you have questions about your treatment plan, you and your Counselor should discuss them
whenever they arise. If your doubts persist, your Counselor will be happy to help you set up a meeting with
another Counselor. The College Counseling Center brief therapy treatment approach is time-limited due to the
natural limits of resources. In order to best serve the needs of our students, those who require long-term and/or
intensive support will generally be referred to community resources for ongoing treatment. Similarly,
students whose needs require a particular type of expertise that is not available in the College Counseling Center
are also referred to community resources. If your Counselor determines that you may need care beyond the
scope of practice of the College Counseling Center, your Counselor will refer you to another health care
provider. Specifically, students may be referred to off-campus providers for a higher level of care, including
for the following: (a) medication follow-up, (b) care outside the clinical expertise of staff, including forensic
threat assessment or substance abuse, (c) long term counseling when short term counseling may be detrimental,
or (d) addressing harassing, violent, or threatening behavior towards Center staff. You will be responsible for
obtaining transportation at your cost to off-site referrals and to work with your insurance company for
payment coverage of such appointments. The SUNY Potsdam Counseling Center is not responsible for these
aspects of treatment.
The Center is staffed by licensed therapists or supervised permit holders working toward NYS licensure. Specific
information about your Counselor’s experience, education and credentials can be provided to you upon request.
Licensed therapists are required to refer clients to, and remain in consultation with, a medical physician in
the case of ongoing treatment of any serious mental illness. Such medical evaluation and consultation shall be
to determine and advise whether any medical care is indicated for such illness. For purposes of this section, "serious
mental illness" refers to schizophrenia, schizoaffective disorder, bipolar disorder, major depressive disorder, panic
disorder, obsessive-compulsive disorder and attention-deficit hyperactivity disorder.
The Center serves as a training site for Mental Health Counseling and Social Work Interns who work under the
supervision of professional licensed staff. Your Counselor may involve an Intern in your therapy. The Intern does
not yet have a New York State License to provide counseling services and works under the direct supervision of a
licensed professional at the Center to attain the experience required for licensure.
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COUNSELING SESSIONS
The Center will conduct a consultation evaluation that will last 45 minutes. If the College Counseling Center is an
appropriate place for treatment, your Counselor will schedule subsequent 45-minute sessions, at a time and
frequency deemed most appropriate by your provider. Once an appointment is scheduled, you will be expected
to attend unless you provide notice of cancellation before your appointment. If you fail to attend a scheduled
appointment, arrive late 10 minutes or more or fail to provide notice of cancellation, you will be charged a
“Counseling No Show Fee” of $20.00. The charge will appear on your student bill. You may appeal this charge by
submitting an appeal request within two (2) weeks of the missed or late appointment. You may reschedule the
appointment by calling (315) 267-2330 or by stopping by the office.
PROFESSIONAL FEES
Short-term counseling is included in your student health fee. Referral services are not included in your student health
fee. You will be expected to pay for any referral services when provided unless you have insurance coverage that
permits another arrangement. You are responsible for making payment and transportation arrangements. It is
very important that you find out exactly what mental health services your insurance policy covers, and inform
your off-campus provider that you intend to utilize your health insurance policy before receiving any services.
Counselors are available after the Center is closed only to provide safety assessments. If you are unsure if you
can remain safe from thoughts of suicide, you should contact Reachout at 315-265-2422 or University Police
at 315-267-2222 to obtain assistance.
If your Counselor will be out of the office for an extended time, your Counselor will provide you with the name of
a colleague to contact, if necessary.
TREATMENT OF MINORS
The Center recognizes the important role of parents and guardians in providing counseling to minor students. If your
parent or guardian is not reasonably available or if requiring parental or guardian consent would be
detrimental to your treatment, the Center may be able to provide services to you without parental or guardian
involvement. Your Counselor would need to determine that you can give informed consent and the treatment is
needed for your well-being. If an exception does not apply and you are under 18 years of age, the Center will require
the written consent of your parent(s) or guardian.
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CONFIDENTIALITY AND RECORDS
Information shared by you in a counseling session will be treated with the strictest confidentiality, and will
not be disclosed without your permission, except when, in the judgment of the Counselor, such disclosure is
necessary to protect you or someone else from physical or psychological danger. This may include consultation
with appropriate professionals to ensure ongoing safety from mental health symptoms. This may also include
reporting a person who is at risk of harming self or other(s) to the Director of Community Services as required by
the New York State SAFE Act. This report could result in the requirement to relinquish all firearms in the near
future and may prevent approval of future firearm applications.
In addition, Counselors must also surrender client records to a court if subpoenaed by a judge.
In cases of formal complaint against the Center, client records may be used or disclosed to demonstrate
acceptable practice standards were followed. Demographical and diagnostic information is also used in
assessment and accreditation.
While information will not be released to an outside agency without your written permission, professionals confer
within the Center and with providers at Student Health Services in order to improve services for you.
INFORMED CONSENT
I have read the information provided above and have had an opportunity to discuss all my questions and concerns
about receiving therapy services at the SUNY Potsdam College Counseling Center. I understand the nature of the
treatment, the risks, the benefits and the alternatives to this treatment. No one has guaranteed me that the counseling
services will have certain results. I have the right to make decisions about my health care, to refuse health care and
to revoke this consent at any time except to the extent services have already been provided. I understand that interns
may be involved in my treatment. I consent to receiving counseling services at SUNY Potsdam College Counseling
Center from my Counselor and the other licensed professionals of the Center. I also consent for my Counselor and
other licensed professionals to discuss my treatment with providers at Student Health Services if I am also receiving
mental health related services at Student Health Services.
Date/Time Signature of Patient Date of Birth
1
Date/Time Signature of Parent or Legal Guardian Relationship to student
1
Signature of custodial parent or legal guardian is required for minors, subject to certain exceptions.
Date/Time Signature of Witness Print Name of Witness
