Vous êtes sur la page 1sur 5

Running head: ETHICAL AND LEGAL DOCUMENT

Professional Disclosure Statement and Informed Consent


Juanita Iturbe
Group Counseling Theories and Techniques
Lamar University

Running head: ETHICAL AND LEGAL DOCUMENT

Professional Disclosure Statement and Informed Consent


This document is designed to provide information concerning your counselors
competency, philosophy, and chosen techniques and to ensure that you understand the
professional relationship of counselor and client. This consent will be explained to you
verbally and I will explain the benefits and risks of counseling and the limits of
confidentiality.
Education and Qualifications
I am a counseling student at Lamar University with a Bachelor of Interdisciplinary
Studies from the University of Texas-Pan American (2005). I graduated from the college
of Education with a minor in Elementary Ed. Bilingual/Bicultural.
As a practicum student in the counseling program, I aim to gain the knowledge and
experience to provide effective counseling services to my clients. I have been described
as an honest and caring. I understand the developmental stages of a persons life and the
basic conflicts one may face through life experiences. My goal is to help clients develop
life skills to acquire positive and successful outcomes. I am described as a
compassionate, honest, knowledgeable, and determined individual.
Professional Affiliations
I hold a student membership with the American School Counselor Association.
Treatment Approach
I work within a specialty area that is appropriate for my clients and me. I use treatments
in which I have had proper education, training and supervised experience. I foster
autonomy, beneficence, nonmaleficence, and justice in all my practices. I will make sure
you are knowledgeable about the group you will be participating in as well as the
intended goals. All of my exercises will be structured and focused on group goals and
needs. Furthermore, all my techniques are data proven and theoretically based in order to
remove barriers in life, become successful, develop the skills to solve problems, and
reach set goals.
As a client, you have the right to terminate our counseling relationship without reason or
explanation. If we reach a point in therapy where either one of us feels progress has
ceased, I will choose to continue only if supervised by a professionally qualified person
or end our therapy sessions. Additionally, referrals may be made if goals are not being
met or conflict arises. I also encourage you to monitor and evaluate your own progress.

Running head: ETHICAL AND LEGAL DOCUMENT


Professional Relationship
Our relationship will be purely professional at all times. Our affiliation will be a
therapist-client relationship throughout all communication and collaborations. My main
responsibility to you is to respect your dignity and promote your welfare (ASCA,
2008). We will work closely together on plans to insure your success. I will document in
case records all interactions. In group settings, I will take all precautions to protect you
from any physical, emotional, or psychological trauma.
Confidentiality
Members in my group have the right to share personal beliefs, emotions, and facts with
the reassurance that it will not be repeated outside of our group. Because trust is the
foundation in our relationship, I will regard any breech of confidentiality as malicious
talk and extremely damaging to the groups progression. Confidentiality must be
maintained to create trust, cohesiveness, and growth (Gladding, 2012, p. 215). I will
make every effort to maintain confidentiality, but will break it if obligated legally or
ethically. Any foreseen harm to yourself or others or legal reasons will cause a breach of
confidentiality. Otherwise, only the client my authorized any disclosure of information.
Notice of Privacy Practices and Clients Rights
I have been given the HIPPA of Privacy Practice and Clients Rights. I understand that the
information given below is my preferred contact information for my privacy rights in
being contacted.
Consent for Treatment of Minors (if applicable)
In the case that in as a parent, I/we consent that my child __________________ may be
treated as a client by the above referenced counselor.
Notice of Privacy Practices and Clients Rights
I have been given the HIPPA of Privacy Practice and Clients Rights. I understand that the
information given below is my preferred contact information for my privacy rights in
being contacted.
Consent for Treatment of Minors (if applicable)
In the case that in as a parent, I/we consent that my child __________________ may be
treated as a client by the above referenced counselor.

Running head: ETHICAL AND LEGAL DOCUMENT


Other Important Information
I,_________________________________, comprehend that in order to reach my goal as
well as my groups goal, I need to be honest to myself and others, collaborative, commit
myself to my groups goals, and treat everyone fairly. I acknowledge that I will experience
a wide range of emotions throughout the group process, and I am willing to work with
everyone involved in my group in a positive productive manner.
Counseling Services: Consumer Rights and Responsibilities (Gladding, 2012, p. 212)
Consumer Rights
Be informed of the qualifications of your counselor: education, experience, and
professional counseling certification(s) and state license(s).
Receive an explanation of services offered, your time commitments, and fee
scales and billing policies prior to receipt of services.
Be informed of how to contact the counselor in an emergency situation.
Request referral for a second opinion at any time.
Request copies of records and reports to be used by other counseling
professionals.
Receive a copy of the code of ethics to which your counselor adheres.
Contact the appropriate professional organization if you have doubts or
complaints relative to the counselors conduct.
Consumer Responsibilities
Set and keep appointments with your counselor. Let him/her know as soon as
possible if you cannot keep an appointment.
Pay your fees in accordance with the schedule you pre-established with the
counselor.
I hereby consent to and agree to receive counseling services and acknowledge that I have
received a copy of the Professional Disclosure Statement for Juanita Iturbe. I recognize
that she is a counseling intern and that at any time I would like to contact her supervisor, I
should do so.
Signatures
Name of Client:
Preferred way to be contacted:
Contact Information
___________________________________Client or Parent/Guardian Signature
________________________Date
Please include the name and phone number of any person you wish for me to
contact in case of an emergency or crisis.
Name of Emergency Contact:

Running head: ETHICAL AND LEGAL DOCUMENT


Contact Information:

Reference
American Counseling Association. (2005). Code of ethics and standards of practice.
Alexandria, VA: Author.
Gladdings, S.T. (2012) Groups: A counseling specialty (6th ed.) Boston, MA: Pearson.