Counseling Center

Client Consent Form

The following is the text of the consent form you will be asked to sign should you seek therapy services at the Counseling Center:

Counseling is a confidential process designed to help you address your concerns, come to a greater understanding of yourself, and learn effective personal and interpersonal coping strategies. It involves a relationship between you and a trained therapist to help you accomplish your individual goals. Counseling involves sharing sensitive, personal, and private information that may at times be distressing. During the course of counseling, there may be periods of increased anxiety or confusion. The outcome of counseling is often positive; however, the level of satisfaction for any individual is not predictable. Your therapist is available to support you throughout the counseling process.


All interactions with Counseling Services, including scheduling of or attendance at appointments, content of your sessions, progress in counseling, and your records are confidential. No record of counseling is contained in any academic, educational, or job placement file. You may request in writing that the counseling staff release specific information about your counseling to persons you designate.

Exceptions to Confidentiality:

  • The counseling staff works as a team. Your therapist may consult with other counseling staff to provide the best possible care.
  • If there is evidence of clear and imminent danger of harm to self and/or others, a therapist is legally required to report this information to the authorities responsible for ensuring safety.
  • New York State law requires that staff of Counseling Services who learn of, or strongly suspect, physical or sexual abuse or neglect of any person under 18 years of age must report this information to county child protection services.
  • A court order, issued by a judge, may require the Counseling Services staff to release information contained in records and/or require a therapist to testify in a court hearing.

Student's Responsibilities:

We appreciate prompt arrival for appointments.You are asked to contact the Office if a situation occurs that will delay you or require you to reschedule an appointment.If you do miss an appointment, it is your responsibility to contact the Office to confirm your next appointment – otherwise the time may be used for another student.

There is no fee for counseling services in our office.

I have read the above information. I understand the risks and benefits of counseling, the nature and limits of confidentiality, and what is expected of me as a client of the Counseling Services.

Signature of Client