Counseling
Center
Personal
Counseling, Academic Support, and Career Counseling
Services
North
Carolina State University
GENERAL
CONSENT FOR TREATMENT AND CONSENT TO USE AND DISCLOSE HEALTH AND MEDICAL
INFORMATION FOR TREATMENT, PAYMENT AND HEALTH CARE
OPERATIONS
Welcome
to the NC State University Counseling Center. This handout summarizes important
information that you should know about our services and provides us with your
written consent to treatment/care by our counselors and other health care
providers as well as your consent to our use and disclosure of your protected
health information for treatment, payment for services, and health care
operations. We ask you to read it
carefully, ask any questions that you may have, and then sign, date and return
the form to us. Thank
you.
The
Counseling Center offers a range of professional services for students including
short -term personal, academic, and career counseling as well as psychological
assessment and psychiatric consultation.
Currently, counseling sessions at the Center are free of charge; there
are, however, fees for career testing and some psychiatry services (please
inquire at the front desk or with your counselor for more detailed information
on our fee schedule). Please note that the Counseling Center does not provide
services that require court testimony, reports, or involve legal
proceedings.
A
counselor may meet with you for one or two sessions to determine the kind of
services that will best meet your needs and whether we can provide those
services at this agency. If we
determine that your treatment needs require resources or competencies beyond the
scope of our services, we will assist with a referral to an appropriate
community agency or mental health provider.
See NC State University Health Care
Components Notice of Privacy Practices.
This is posted in the reception area
and is available on the Counseling Center home page at www.ncsu.edu/student_affairs/counseling_center/privacy.html. You may also ask at the front desk for a
printed copy of the notice.
§ Complete
Paperwork
All
students who come to the Counseling Center are asked to complete paperwork
before scheduling an appointment for an initial
consultation.
You
are expected to attend and be on time for all scheduled appointments. If you are unable to attend a session
due to illness or an emergency, please cancel your appointment at least 24 hours
in advance.
To
benefit from the services you receive requires being prepared for your sessions,
actively participating with your counselor, and carrying out plans made with
your counselor.
If
you wish to comment on the services you have received, you may do so at any
time. Comment cards are available
at the Front Desk for your convenience.
You may be asked to provide a more formal evaluation of the services you
receive at the Counseling Center.
Your feedback is essential to our continuing effort to improve the
quality of our services.
May
We Call You?
At
times, Counseling Center staff may need to contact you regarding scheduling or
other issues. If you would like to
be contacted for such reasons, please indicate the telephone numbers that can be
used to reach you in the space provided below.
Phone
1___________________________________ Phone
2____________________________________
May
we leave a brief confidential message? Yes
( ) No ( )
If
yes, please indicate where (e.g., voice mail, answering machine)
______________________________
Emergency
Contact Information:
In
the event of an emergency, whom should we contact?
Emergency
Contact
Person_______________________________________________________________
Home
phone ______________________________ Work phone
_________________________________
CONSENT
I
have read the above material regarding rights and responsibilities of
Counseling Center clients, understand its provisions, and agree to receive
Counseling Center services under the above conditions. I further grant consent to the
North Carolina State University Counseling Center to use and disclose my
protected health information for the purposes of treatment, payment for
services and healthcare operations. Name
(please
print)
______________________________ Student ID:
______ ______ _______ Signature_____________________________________________________ Date_________________