OBERLIN COLLEGE

 

THE COUNSELING CENTER

247 West Lorain Street, Suite D

440-775-8470

 

 

CONSENT FOR TREATMENT

 

I hereby agree to treatment at The Counseling Center.

 

I understand that all information regarding diagnosis and/or treatment is confidential and will not be released to any other agency or individual without my knowledge and written consent, except when required by law.  I understand that the Center and my counselor are required to report knowledge of current child abuse.  I also understand that the Center and my counselor may be released from confidentiality statutes if there is a serious intent to harm myself or others. I have been provided a Counseling Center brochure, which includes an emergency hotline telephone number, and other emergency and crisis information.

 

 

I further understand that my counselor may consult with other professionals at The Center in order to provide the best treatment possible for me.  Staff and the consulting psychiatrist may also speak with each other, as necessary, concerning my care, and with Student Health if medical consultation is indicated.

 

Furthermore, since The Counseling Center is also a training center and my counselor may be a trainee, I understand that all trainees are supervised and that my situation will be discussed with my counselorŐs supervisor.  The intention of supervision is to promote the highest quality care.  To that end I may be asked by my counselor to have my sessions videotaped and/or audiotaped.  If I am to be taped, that process will be discussed with me.  I also understand that demographic data is collected and stored on a database for possible anonymous reports.  At all times my privacy and care will be treated with the highest regard.

 

Email is not a secure medium and confidentiality cannot be ensured; nor is it a reliable method of contacting counselors in crisis or non-crisis situations.  Please telephone the Center to ensure prompt, confidential staff response.

 

In the event that The Counseling Center must contact me, I give my permission in order of preference:

 

            o telephone call                     o note to OCMR                      o email message

 

 

If you are unable to keep an appointment, please call the office 24 hours in advance or your absence will be counted as a session.

 

 

I have read, understand, and agree to the foregoing.

 

 

                                                                                                                                                           

                                    Signature                                                                           Date

 

 

                                                                                   

                                Name Printed