AMHERST COLLEGE COUNSELING CENTER
INFORMED CONSENT FOR TREATMENT
Welcome to the Counseling Center. We look forward to assisting you. The Counseling Center clinicians include licensed
psychologists, licensed social workers, licensed mental health professionals, psychiatrists, and those supervised by psychologists.
You may be meeting with a pre-doctoral psychology trainee, who is completing a placement in the Counseling Center for this
academic year. Each trainee practices under the license and supervision of one of the licensed psychologists on staff. In essence, by
agreeing to work with a trainee you benefit from the added input on your case that trainees receive in their weekly supervision.
Individual psychotherapy sessions are typically scheduled for 45 minutes and on a weekly or every other weekly basis. At the end
of a session, you may schedule the next session for a mutually agreeable time. Please be aware that you might not be able to meet
on the same day and time on a consistent basis due to the demand for services. If you need to cancel or reschedule an appointment,
please notify us as soon as possible so we can schedule someone else in the available time period. When needed, we generally
communicate by email with clients outside of psychotherapy sessions. Email is not a secure mode of communication. If you are not
comfortable with such use of email please discuss this with your clinician.
Administrative Neutrality
The Counseling Center is administratively independent and neutral (i.e. it is not responsible for college admissions, administrative,
housing, or disciplinary decisions involving students) and, therefore, your participation here is confidential and voluntary.
Information about your contact with the Counseling Center will not be shared with others outside of the Counseling Center without
your informed consent, except in specific circumstances described below.
Confidentiality
In accordance with Massachusetts’s law, we want to explain to you the meaning of confidentiality and the exceptions to it at the
outset of psychotherapy. We ask that you read the information provided here and ask any questions you wish. All sessions with a
psychologist, social worker, counselor, psychiatrists and clinicians supervised by psychologists are confidential. The staff members
will not give out any information about you to your parents, friends, professors, administrators or others without your permission
except in these circumstances:
Counseling Center providers have the discretion to compromise the confidentiality of your communications with them if you
threaten to do harm to yourself or another individual and they reasonably believe that you may act on that threat. In such situations,
the psychologist, psychiatrist, social worker or counselor ordinarily will arrange for you to be evaluated by a psychiatrist or
clinician in a hospital setting. It may also be necessary to contact family members or others who can help to provide for your safety.
In cases of threats or actual violence toward another, the clinician is legally obliged to take protective actions which may include
notifying the potential victim, campus security and/or the police in the potential victim’s community. Psychologists, psychiatrists,
social workers and counselors are mandated reporters and are required to breach confidentiality by filing a report with the
appropriate state agency if you report to us that a minor (under age 18), elder, or person with a disability is being abused.
Communication during psychotherapy meetings is privileged, meaning that you have a legal right to prevent the clinician from
testifying in most judicial hearings, even if a subpoena is issued. Exceptions to this are that a judge may require testimony in certain
legal cases where a client has died or if you are involved in a child custody and adoption proceeding, lawsuit in which your mental
condition is an important aspect of the case, legal proceeding related to psychiatric hospitalization, malpractice or disciplinary
proceeding against the psychologist or social worker, and court ordered psychological evaluation.
Treatment of a Minor
If you are under 18 years of age, your parent or legal guardian must consent to your treatment and the Counseling Center reserves
the right to advise your parent(s) or legal guardian about developments which could significantly affect your health or well-being at
the College. In such situations, the contents of specific meetings between you and a counselor, social worker or psychologist will
not be discussed but your overall progress may be discussed in general terms. Therapists may release certain information without
your consent to either your parent (s) or legal authorities under the following circumstances:
* You tell your therapist that you plan to cause serious harm or death to yourself or someone else, and your therapist believes you
have the intent and ability to carry out this threat in the very near future. Your therapist must take steps to inform a parent or
guardian of what you have told them and how serious they believe this threat to be; if you intend to harm someone else, your
therapist must inform this person.
* You are doing things that could cause serious harm to you or someone else, even if you do not intend to harm yourself or another
person. In these situations, your therapist will need to use their professional judgment to decide whether a parent or guardian should
be informed.
* You tell your therapist you are being abused physically or sexually or that you have been abused in the past. In this situation, your
therapist may be required to report the abuse to Massachusetts Department of Children and Families or law enforcement.
Additionally, when a child abuse investigation is being conducted the Counseling Center providers must permit a state child abuse
team to inspect and copy client records without the consent of the child, or the child’s parent/guardian.
* You are involved in a court case and a request is made for information about your counseling or therapy. If this happens, your
therapist will not disclose information without you and possibly your parents’ written agreement unless the court requires them to
do so. Your therapist will do all they can within the law to protect your confidentiality, and if your therapist is required to disclose
information to the court, they will inform you that this is happening.
EXCEPTION: Parental and/or guardianship consent does not apply if a parent refuses to be involved; if there are clear clinical
indications to the contrary; if the minor has been sexually abused by a parent; or if the minor is legally emancipated. However,
exceptions to confidentiality may still apply to legal authorities if any of the above circumstances arises.
COMMUNICATING WITH YOUR PARENT(S) OR GUARDIAN(S):
Except for situations such as those mentioned above, unless you provide your written and/or verbal consent, your therapist will not
tell your parent or guardian specific things you share with them in private therapy sessions. This includes activities and behavior
that you think your parent/guardian would not approve of -- or would be upset by -- but that do not put you at risk of serious and
immediate harm. However, if your risk-taking behavior becomes more serious, then your therapist will need to use their
professional judgment to decide whether you are in serious and immediate danger of being harmed. If your therapist thinks that you
are in such danger, they will certainly talk with you and discuss how best they can share this information with your parent or
guardian.
Consultation
We consult with our two in-house psychiatrists regarding clients as necessary. The staff may also engage in professional
consultations with other appropriate professionals about their assessment and/or treatment of you in order to enhance the services
provided to you. Efforts would be made to avoid revealing your identity. Any professional consulted on your behalf would also be
legally bound to maintain confidentially.
Concern for Someone Else
If you have come to the Counseling Center due to concerns about someone else, we would like to support you and respond to your
needs. We feel that the best way to do that is to have a session with you, discuss your concerns, and develop a plan. There are
consultation situations where we hear information that raises concern that the student in question or someone else may be in danger
or that the information provided to us could have clinical relevance for a student in our care. In these cases we will evaluate the
information provided to us and decide whether or not we need to initiate a course of action to reduce the risk of harm or improve
treatment. For these reasons, we cannot guarantee confidentiality during a consultation session. In these situations, we would
discuss our plans with you and support you through whatever action is needed. Please also note that we keep records of all sessions,
including consultations. It is possible that these records will be attached to the student of concern’s file.
Keefe Health Services Offices
When students are seen for psychiatric or psychotherapy services in our Student Health Services offices, it is possible that some
Student Health Service personnel will be aware of your attendance. These personnel are also bound by MA laws of confidentiality
and will not discuss your attendance of appointments with others.
Records
Records of sessions with a psychologist, social worker, counselor, or psychiatrist are maintained and kept secure in the Counseling
Center's Electronic Medical Record system. Records are destroyed after seven years. They are not part of your college educational
record. You have the right to know the contents of your file. To learn what is in your file, submit a written request to the Director
and a mutually agreeable time will be set to discuss this request with you.
I certify that I have read and understand the above information and that I am voluntarily consenting to treatment.
__________________________________________________ __________________________________________________
Student Signature Date Intern Signature (if applicable) Date
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Parent/Legal Guardian Signature (if applicable) Date Clinician Signature Date