DRAKE UNIVERSITY

Counseling Program
Consent to Interview and Record
The Counseling Program at Drake University requires Counseling Practicum Students to record
counseling sessions with students/clients/consumers for the purpose of evaluating and
improving their counseling skills. All recordings will be kept confidential. The recordings will be
viewed by the Counseling Practicum Students supervisor and parts of some sessions may be
shared with other Counseling Practicum Students for the purpose of providing feedback.
Recordings of session are made for educational and training purposes for Counseling Practicum
Students. The recordings are in no way part of any records at the school or agency where you
or your child is a student/client/consumer. At the end of each academic term all recordings will
be destroyed.
I give permission for Emily James to record counseling sessions with my student/child for
training purposes. I understand that recordings will be kept confidential and that they will be
destroyed at the end of the academic term (May of 2016). I also understand that I can choose to
withdraw my student from these sessions at any time.

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Print Name Student/Client/Consumer

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Print Name Parent or Guardian if Student/Client/Consumer is under 18

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Signature Parent or Guardian Date

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Signature of Counseling Practicum Student Date

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