INFORMED CONSENT FORM

As a client of Aashray Mental Health and Counseling Center , your well-being is your therapist’s top priority. Therapy is a relationship that works, in part, because of clearlydefined

rights and responsibilities held by each person. Your therapist will use his or her professional judgment to determine your appropriate course of therapy. This consent form helps to create the safety to take risks and the support to become empowered to change. This form is also intended to inform you about your rights as a patient, limitations to those rights, and your therapist’s corresponding responsibilities. The consent you provide herein will last the entire duration of your treatment unless you revoke or modify your consent in writing. Do not agree to the terms and conditions of this informed consent form unless you completely understand and agree to all aspects.

Risks and Benefits of Counselling

Counseling can be an effective tool in helping students cope with emotional, relational, and developmental concerns. Counseling provides you with a safe environment to talk about your concerns with a licensed professional trained to provide treatment. The therapeutic relationship is unique because it is highly personal.

The benefits of counseling can include helping you develop coping skills, make behavioral changes, reduce symptoms of mental health disorders, improve the quality of your life, learn to manage anger and other emotions, and learn to live in the present, along with other advantages. At the same time, counseling can also be a difficult process. In the course of your treatment, you may experience difficult emotions or encounter unpleasant memories.

Ultimately, counseling is not an exact science and your therapist cannot guarantee any specific therapeutic outcome. Your therapist will, however, use his or her professional judgment to provide you with the best treatment possible.

Client Rights

As a client, you have the right to:

• Be treated with dignity and respect.
• Expect your counselor to keep your treatment confidential, except as noted further Herein.
• Ask questions about your treatment.
• Be informed about diagnoses, treatment philosophy, method, progress, and prognosis.
• Participate in decisions regarding your treatment.
• Obtain any assessment results and have them explained to you in a manner that you Understand.
• Refuse treatment methods or recommendations.
• End counseling at any time (though we ask that you please discuss your reason for wanting to end counseling with your counselor).

Client Responsibility

You have responsibility to:

• Maintain your own personal health and safety.
• Take an active role in the counseling process, including honestly sharing your thoughts, feelings, and concerns.
• Help plan and follow through with your therapeutic goals.
• Provide accurate information regarding past and present physical and psychological problems (including hospitalizations, medications, and/or prior treatment).
• Provide notice of your desire to terminate the counseling relationship before entering into a counseling relationship with another provider.
• Keep scheduled appointments (contact your counselor in advance to cancel and/or reschedule appointments).
• Inform your counselor if, during the course of treatment, you become aware of any conflicts of interest with another patient or College Counselor; and
• Promptly notify your counselor of any problems or concerns that render you unable to participate in counseling.

Confidentiality

Professional counselors recognize that confidentiality is essential to an effective counseling relationship. With a few exceptions (noted below), everything you share throughout your counseling treatment, including your identity, is confidential.

Exceptions to patient confidentiality include, but are not limited to:

• Danger to self or others.If your counselor believes you intend to harm yourself or someone else, your counselor is bound by laws and ethics to take steps to prevent that harm from occurring.
• If you are a minor (under age 19), your parents or legal guardian(s) have access to your records and discretion over them.
• If you disclose abuse or neglect of a child, an elderly person, or anyone who is similarly defenseless, your counselor is required by law to report the abuse.
• If you are in a group counseling setting, your counselor must still maintain confidentiality of the group. However, your counselor cannot guarantee that group members will also maintain confidentiality.
• If a third party issues a lawful subpoena for your records, your counselor may be legally obligated to disclose your records. Your counselor will ensure you are notified of any subpoena and, as required by law, take steps to ensure the records are produced subject to a protective order.
• If your counselor is required by law to disclose your records, your counselor may disclose information necessary to comply with such law.

Discharge Based on Professional Judgment

If your counselor determines that your needs go beyond his or her level of expertise, he or she has an ethical obligation to refer you to another professional who can provide the care you need.

This might include, for example, a specialized counselor, medical care provider, psychologist, or psychiatrist.

If, based on professional judgment, your counselor determines he or she cannot provide (or continue to provide) treatment to you, your counselor may discontinue treatment and, as appropriate, refer you to another provider.

I acknowledge that I have read and understand ALL of the above information and I am fully aware of my rights and benefits and risks of counselling If I have any questions or concerns about any of this information, I agree to discuss these concerns with the counselor.