COUNSELING: Counseling is a pathway to change in life. Regardless of your motivation for change through counseling, I will offer you the best professional assistance I can provide. Although there can never be absolute guarantees, I have found that working as a team with my clients, with concerned effort on their part, is the most productive approach to positive outcome.

As your counselor, I am responsible to provide you with the highest level of professional skills corresponding with my training and experience. For example, I will assist you with communication. I will offer "homework" which may consist of reading or other activities. I may suggest a visit to your physician if I believe it is necessary. During your counseling experience, I will encourage, guide, challenge and support you to make the changes you decide for yourself.

As my client, your responsibilities include openness, honesty and commitment. Any one, or all, of these may be difficult for you. While effort and risk are necessary for you to accomplish your desired results, you may feel pain and/or anxiety as we work together. This is a normal part of the counseling process.

ETHICAL INFORMATION: I am licensed by the state of Florida as a Mental Health Counselor, Mental Health Counselor-Intern, Marriage and Family Therapist, Clinical Social Worker, or Social Work Intern. Any question or complaint about my counseling services that cannot be resolved between us should be directed to the Department of Health, Division of Quality Assurance in Tallahassee.

The Director of Social Services Programs can and will observe one or more counseling sessions with the purpose of supervising clinical interns. As part of that supervision, counseling sessions may be audio- or videotaped with the prior knowledge and permission of the client. Your Counselor (a graduate student) receives consultation and suggestions from the supervisor(s) reviewing the sessions. In some instances, other graduate students-in-training or professionals will participate in these conferences. These activities are intended to ensure that you are receiving the highest level of quality service. You have the right to request the name and/or speak with the supervisor.

CONFIDENTIALITY: Normally information disclosed by you and/or your child during counseling will be kept strictly confidential and will not be revealed to anyone without your permission. It is important for you to know that there are some exceptions to confidentiality. If an exception should arise, I will make every effort to inform you, before doing so, of the necessity to break confidentiality.

Exceptions to Confidentiality:

• If you threaten harm or death to yourself or another person, I am legally, ethically and morally required to take action to protect the safety of the threatened person. Actions could include informing the intended victim, arranging for hospitalization for you and/or your child, notifying family and/or support system, or alerting law enforcement.
• If abuse or neglect of a child, aged person or disabled person is known or suspected, I am required by Florida law to report my concerns to the Department of Health and Rehabilitative Services.
• If I were to receive a legally binding Court Order for your counseling records or for my deposition or court testimony, I would be required to comply.
• If you or your child are in counseling or are being evaluated by Order of the Court or as condition of continued employment, I may be required to provide the Court or the Employer with reports, documents or testimony.

CONSENT FOR COUNSELING: I have read and understand the information contained in this form and voluntarily agree to participate in counseling and/or consent to the participation of my child in counseling.