Counseling Services Informed Consent

The Counseling Center provides services at no cost to students currently enrolled in 4 or more hours at

Middle Georgia State University. Students must be attending class at the time counseling is sought.

Our hours for Fall and Spring semester are 8:00 a.m. to 5:30 p.m. Monday through Thursday, and 8:00

a.m. to 12:00 p.m. on Friday. Our hours for Summer semester are 7:30 a.m. to 6:00 p.m. Monday through

Thursday, and closed on Friday. Academic, career, and personal counseling are provided on an appointment

basis. In addition, outreach services such as seminars, and workshops are provided. Appointments are made

in person, by email, or by phone. Participation is voluntary.

ELIGIBILITY FOR SERVICES

The Counseling Center provides individual counseling services only to currently enrolled students using a

brief counseling model for short term counseling. Brief counseling is often effective for common issues

faced by college students and using this model allows us to serve a greater number of clients with our

available resources. The Clinician reserves the right to limit sessions as needed for clients. Clients

identified as needing a referral will be assisted with locating an appropriate off‐campus mental health

provider. Off‐ campus referrals for family or couples counseling are also available. Counselors who teach

academic classes may not counsel students who are enrolled in their course(s). Clients who enroll in their

current counselor’s class will be required to transfer to a different counselor or discontinue counseling

services on campus during that semester.

Minors seeking treatment: If you are under 18 years of age, you are not legally able to consent to

treatment, and consent must be obtained from a parent or guardian. Minors under the age of 18

must understand that parents' may have access to records based on Georgia law. We will try to

provide them only with general information about our work together, unless there is a high risk of

harm to yourself or someone else. In this case, Counseling Center staff will discuss their concerns

about your safety with your parents. If possible, Counseling Center staff will discuss the matter

with you before giving your parents any information and do our best to involve you with this

conversation.

CONFIDENTIALITY

The Counseling Center adheres to strict confidentiality guidelines set by each professional’s national &

state ethical codes/guidelines. All conversations, both by telephone and in person, are confidential.

Communications will be made by phone and/or email (unless otherwise requested by the client). Any and

all records kept by The Counseling Center staff relating to clients, 18 years of age, or older are kept

confidential, except in these cases:

a. When the client is determined to be a threat to the health & safety of him/herself or another,

including abuse of a child, elder or disabled adult. If a counselor determines a client’s personal

safety or the safety of another person is at risk, counselors are required by law to take protective

actions. This may include notifying family members or other emergency contacts, contacting the

police, seeking hospitalization for the client, notifying potential victims of harm or contacting

others who can help provide protection. In the case of abuse, counselors are required by law to

notify the appropriate state agency. If any of these situations occur, every effort will be made by

your counselor to fully discuss the situation with you before taking any action.

b. When documents are court ordered to be released to the property of the court.

c. When Counseling Center professional staff/interns discuss case material for the purpose of

consultation, supervision, or treatment team planning.

d. When an ACT Report about the client that involves threat of harm to self or other(s) is submitted

to the campus ACT team.

e. When the client has given consent to share specified information with identified person(s).

f. Clients under age 18 must have a parent/guardian sign this form before treatment begins. The

client, counselor & parents will together identify confidentiality parameters for future treatment.

g. Client names and appointment information is shared with front office staff at each campus

location. (Please see information below in the Additional Information section regarding records

management policies.)

ADDITIONAL INFORMATION

Initial Appointment: During the first appointment, clients will meet with a counselor to discuss the

problem that led to seeking counseling and to provide personal history and background information.

Initial appointments are 60 minutes in length. At the conclusion of the initial meeting, treatment

options will be discussed, including whether or not counseling needs may be better met by an off

campus counselor or physician. If counseling with the MGA Counseling Center is appropriate, future

appointments may or may not be with the same counselor depending on scheduling and the nature of

the treatment issues.

a. Individual sessions are up to 45 minutes in length. Active participation in the counseling

process is necessary for counseling progress. Noncompliance with treatment recommendations

may necessitate early termination of services. Your counselor will work with you to help

determine what treatment is in your best interest.

b. Hard copy client records are shredded after 7 years. Computerized client records will be deleted

after 7 years.

c. Computerized & hard copy client records are accessible only to Counseling Center staff. The

Counseling Center will be responsible for storing general client records and managing client

information related to scheduling appointments. Counseling session records will be maintained

separately in the counselor of record’s office. Computerized records are password protected.

Counseling Center records are not part of MGA student records.

d. E‐mail, mobile phone text messaging & facsimile are not secure media; therefore, confidentiality

of e‐mail & facsimiles cannot be guaranteed. Urgent or emergency communications should not be

sent via email or fax since timeliness of response to a facsimile or email message cannot be

guaranteed. Social media such as Facebook, LinkedIn, Twitter, Pinterest, etc. are not appropriate

means of communication with your counselor as those media may compromise your

confidentiality & privacy and blur the boundaries of the professional counseling relationship.

Friend or contact requests sent to counselors by current clients & some former clients will not be

accepted. If you and your counselor do choose to communicate via email, those messages should

be limited to only administrative purposes, such as making or cancelling an appointment.

Discussion about counseling session content should be limited to face to face or phone

communication

e. By signing this document, you are indicating your agreement that your participating in counseling

services will not include calling a counselor as a witness in a court proceeding. Be aware that

once counseling services are initiated, it is unethical for your counselor to give any

opinion/recommendation about issues in a legal/court setting such as custody/visitation

arrangements or other legal issues, even if your counselor is compelled by a judge to be a witness.

MGA counselors are not considered forensic experts in legal matters. If a counselor is required by

a judge to testify, counselors are ethically bound not to provide an opinion about a legal matter.

Be advised that MGA & the Counseling Center will attempt to prevent testimony from occurring.

f. All Student workers in the Counseling Center are bound by a written and signed Confidentiality

agreement.

CLIENT RIGHTS AND RESPONSIBILITIES

a. You have a right to confidentiality within the limitations described above.

b. You have the right to be involved in your goal setting/treatment planning process & to be

informed of the professional members of your treatment team. It is the client’s responsibility to

make a good faith effort to fulfill the treatment recommendations suggested by your therapist.

These recommendations include efforts such as attending appointments as suggested by your

counselor, being actively involved during sessions, completing homework assignments, following

up with a medication evaluation referral & taking medications as prescribed by your physician,

experimenting with new ways of doing things, openly & honestly voicing your opinions, thoughts

& feelings, whether negative or positive & implementing any crisis response plan recommended

by your counselor. If you have concerns about treatment suggestions, you are encouraged to

express them to your counselor to avoid any misunderstandings.

c. If during the counseling process your counselor determines he/she is not effective in helping you

reach your counseling goals, or if long‐term or more specialized treatment is warranted, your

counselor is obligated to discuss this with you and, if appropriate, provide appropriate referrals &

terminate treatment.

d. You have the right to be informed of any potential benefits or risks associated with your

treatment. It is not uncommon for symptoms to worsen before they improve. Participation in

counseling can result in a number of benefits to you, depending on your counseling goals.

Working toward these benefits requires effort on your part.

e. You have the right to refuse treatment & to be involved in determining length & frequency of

your treatment.

f. You have the right to receive treatment from competent mental health care professionals who

respect your individualized needs.

g. You have the right to request another mental health care professional within the department or a

referral to an outside professional. Before requesting a transfer to another in‐house therapist, we

encourage you to discuss your concerns with your therapist or the Counseling Center Director.

(You have the right to be informed of reason for referral.)

h. For clients 18 years of age or older, access to records/treatment information is available only

with a written release of information form, signed by the client.

i. Cancellations must be made at least 24 hours in advance. It is the client’s responsibility to

reschedule any missed or cancelled appointments. Clients who miss more than 3

appointments per semester may lose eligibility for services. If you are more than 10 minutes

late for an appointment, the Clinician reserves the right to reschedule your appointment.

EMERGENCY SERVICES

In the event of an emergency in which you are unable to reach the Counseling Center,

call 9-1-1, the Georgia Crisis and Access Line at 1-800-715-4225, Be Well mental

health support line at 833-646-1526 or immediately obtain safe transportation to the

nearest hospital emergency room

I have read & understand the above statements. I have had the opportunity to ask questions about

the statements above & have been provided with a copy of this form. The Informed Consent is valid

for one year from the date of signature.

Client Signature Date Therapist Signature Date

Parent/Guardian Signature (if client under 18) Date