Counseling Center Disclosure Statement
Welcome to the Counseling Center
We want your experiences here to be positive and growth promoting. We have designed this disclosure statement to inform you about us and about your rights as a client. We ask you to sign the form to verify that you have received this information. Please take your time, read this carefully, and ask your counselor if you have any questions. You may also download the
Disclosure Statement (PDF)
Our goal is to provide consultation, evaluation, and counseling services for students dealing with issues impacting their well-being. Our focus involves counseling within a brief intervention framework to maximize your time with your counselor and to offer the most helpful therapy experience. Community referrals may be made for clients needing or requesting long-term therapy. We work with students in exploring new approaches to the issues they are dealing with. This may include problem solving techniques, healthy decision making, and cognitive and behavioral strategies for coping and managing thoughts, feelings, and behaviors. Information about the experience, training, and approaches of our professional staff is available for you at the front desk.
A range of options may be discussed following an assessment of the need for mental health services. Please inquire about current therapy/support group offerings. Our services include:
- Individual mental health counseling.
- Couples therapy
- Therapy groups, which generally begin and end each quarter and meet once a week.
- Support groups, which generally begin and end each quarter and meet once a week.
- Referrals to another TESC office, Health Center, support group rather than or in addition to the Counseling Center direct services listed in this section.
- Referrals to community counselors, groups and other supportive services and resources.
- Providing educational information and/or resources for you to learn more about issues you may be dealing with.
To be eligible for counseling you must be an enrolled TESC student who has paid the quarterly Student Health and Counseling Fee. Because demand is high, and in order to best serve our student community, the following session limits apply:
Students may be seen up to 12 individual sessions during the regular academic year, not to exceed 8 sessions in any one quarter. Individual sessions are scheduled for up to 50 minutes at a frequency to be determined by the student and his or her counselor.
- Students and their partners may be seen for couple's counseling even if the partner is not a student. Couple's sessions are scheduled for up to 50 minutes at a frequency to be determined by the student and his or her counselor.
While individual and couple's sessions are limited to 8 counseling sessions in any given quarter, participation in therapy groups or support groups does not count toward this total.
When referrals to the community are made
- When students prefer to be seen off-campus.
- When the type of problem is not within the professional capacity or expertise of the Counseling Center staff, or when long-term therapy is indicated.
Scheduling the initial assessment
To best determine students' counseling needs and/or appropriate referrals an initial assessment session will be scheduled with you. To schedule this appointment we will need:
- Your current phone number and address. If your phone number or address changes after filling out our paperwork, it is your responsibility to notify us of these changes.
- Current e-mail information. If you choose this form of contact, please be sure to initial the consent statement at the end of this form acknowledging your request to be contacted electronically (remember, e-mail is in the public domain and confidentiality cannot be guaranteed).
- Your intake questionnaire. We will not schedule an initial session until this three-page document is completed and returned to our office. We require this so that we have enough information to arrange your initial appointment with the provider who will be the best fit for your needs and requests.
- If we are unable to reach you with the information you have provided, we will assume you no longer need our services.
- However, if you have valid contact information but have requested that messages not be left, our attempts to schedule an appointment for you will be restricted. Consequently, if you have designated that messages cannot be left, it is your responsibility to contact us on a weekly basis to see if you have been scheduled for an intake. In the event you have been assigned to a counselor and one week passes without hearing from you, we will assume you no longer need our services.
Assignment to a Counselor
We will attempt to match you with a professional counselor or student intern counselor (currently in a doctoral or masters level academic program) who can best meet your needs, following your initial assessment. Counseling staff meets daily to review requests for counseling services along with information collected during the assessment and completed intake information provided by the student. Based on this information, assignments to counselors are made with consideration of appropriate fit and the availability of individual counselors. Once assigned to a counselor, we will need to contact you to arrange an initial appointment.
Training And Supervision of Counseling Center Interns
All interns are under the direct daily supervision of Counseling Center staff and will discuss your treatment plan and progress with their supervisor on a regular basis. As part of the Counseling Center's training function, sessions may be recorded for supervision purposes (video- or audio-taped), and some may be observed directly through a closed-circuit video. If you are not working directly with an intern, it is possible that, on some occasions, an intern might observe a counselor's session.
In the event of a taped session, you will be notified in advance and permission from you will be requested. When a session is taped, interns may review the recordings or portions of the recordings with their supervisors, who will then discuss and provide feedback about their session. Once recordings have been reviewed, they will be erased. Prior to being reviewed, they will be stored in a locked area.
In the event of an observed session, you will be notified in advance and permission from you will be requested. An intern observing a session is watching the staff member, just as a supervisor observing a session is watching the intern.
Because supervision is an important aspect of an intern's training, we encourage you discuss any concerns or questions about supervised counseling sessions with your counselor.
Contact From The Counseling Center
If you have indicated that it is all right for us to leave a message for you, we will call and leave a message either offering a tentative appointment or requesting that you call our center to arrange your first session.
- It will then be your responsibility to contact the Counseling Center to confirm a tentative appointment or decline the offer of counseling by calling our confidential voicemail at (360) 867-6800. The voicemail is available 24 hours a day and is our preferred method of communication, since we cannot guarantee the confidentiality of anything sent through e-mail.
- If we do not hear back from you within the day, a second call will be made the following day.
- If we do not hear from you within two business days following the second call, we will assume you no longer need our services and you will need to contact our center again in the future.
- If you have requested that no message be left, it is your responsibility to contact us on a weekly basis. In the event you have been assigned to a counselor and one week passes without hearing from you, we will assume you no longer need our services.
When Immediate Assignment is not Available
If our counselors have no open slots:
- You may be offered referrals to providers in the community to expedite the process of being seen.
- You may be placed on our waiting list, or both.
- You must fill out and submit the initial paperwork in order to be on the waiting list.
- If you have not heard back from us within two weeks after adding your name to the wait list, please check back with us.
The waiting list will be continually assessed throughout the academic year. Once assigned to a counselor, our attempts to reach you will follow the policy detailed above. If we do not hear back from you after these attempts, we will remove you from the waiting list. Please let us know if you are on the waiting list and plan to be out of town. Also, please let us know if you are on the waiting list and no longer want our services.
The Counseling Center is open during Fall, Winter, and Spring quarters. The center is closed Fridays after 3 p.m., weekends, holidays, Winter Break, Spring Break, and during the summer.
Cancellation Policy and "No-Shows"
As there is a high demand for our services and often a wait list, we require at least 24 hours notice if you need to cancel or reschedule your appointment.
- If you "no-show" for your appointment (i.e., do not come to your session), fail to cancel within 24 hours, or come more than 15 minutes late for the start of your session (in which case, you will not be seen), your student account will be billed a $25.00 fee and this will be noted as a "no-show."
- In the event you miss an appointment (due to a cancellation or a no-show), it is your responsibility to reschedule with us.
- If you "no-show" a scheduled appointment, you must contact our center and/or reschedule within one week (i.e., seven days) of the initial appointment.
- Similarly, if you cancel a scheduled appointment, you must contact our center and/or reschedule within one week (i.e., seven days) of the initial appointment.
- In either case, if one week has passed and we do not hear from you, we will assume you are no longer interested in our services. If you call back after one week has passed, you will be assigned to your previous counselor only if immediate assignment is available. If immediate assignment is not available, you will be added to our waiting list.
- If you "no-show" for two appointments in one quarter, you will not able to use the services of the Counseling Center until the following quarter. If you seek counseling after that point, you will be assigned to your previous counselor only if immediate assignment is available. If immediate assignment is not available, you will be added to our waiting list.
- If you cancel two appointments in one quarter your counselor will review your case for continued eligibility; you may or may not be eligible to continue based on the review.
Communication of intent to continue counseling after quarter break
- It is your responsibility to contact the Counseling Center by the fifth day of the quarter (i.e., the end of week one) to confirm your intent to continue counseling.
- If you have a scheduled appointment during the first week, you may fulfill this requirement by coming to your scheduled session.
- If you are planning to schedule an appointment once the quarter begins, you will need to let us know your intent to make an appointment (even if you don't have your schedule yet) by the fifth day.
- If you do not contact the Counseling Center by the fifth day, we will assume you are no longer interested in our services.
Counseling is a voluntary act, and you have the right to choose counselors who best suit your needs. We will do our best to accommodate your needs or to give you an appropriate referral. You have the right to be treated ethically by your counselor. If you have any questions concerning your rights and/or ethical treatment, or if you wish to file a complaint, please contact one of the following:
- Your current mental health counselor
- Elizabeth McHugh, Director of Health & Counseling, at (360) 867-6808
- The Washington State Department of Health at (360) 236-4700
We observe confidentiality within the TESC Health & Counseling Centers as required by RCW 18.19.180. To provide effective service, your therapist may discuss your case with others working in or for the Counseling Center (i.e., the consultant psychologist, other counselors, and/or the receptionist). Also, within the Health & Counseling Centers, Counseling Center staff may consult with Health Center staff on an as-needed basis (please see RCW Chapter 70.02 for rules about this consultation). However, no information about you is given to anyone outside of the TESC Health & Counseling Centers, including parents, partners, roommates, employers, faculty, or other Evergreen staff, unless:
- We have your written permission.
- We believe it is necessary to prevent clear and imminent danger to you or others.
- You indicate that there is reasonable cause to believe that a child, dependent adult, or a vulnerable elderly person has been abused.
- A court orders us to disclose confidential information about you. If this happens, we will first ask that the court drop their order. If they refuse to drop their order, we will disclose only the minimum amount of information we deem necessary to satisfy the court's order.
- You waive the privilege by bringing charges against us.
If you have any questions about confidentiality, please talk to your counselor.
PLEASE SEE FINAL PAGE FOR SIGNATURES AND REVIEW OF THE ABOVE INFORMATION
I have read and fully understand the preceding description and conditions of The Counseling Center's services, procedures and policies. I agree to permit my counselor to discuss the nature of my problems with other Counseling Center Staff. I understand this Disclosure Statement and I consent to counseling. Additionally, I consent to the following:
- If I "no-show" for my appointment, fail to cancel within 24 hours, or arrive more than 15 minutes late for an appointment, I will not be seen, will need to reschedule, and understand that my student account will be billed $25.00. After a missed appointment (either due to a cancellation or a "no-show"), I have one week to contact the Counseling Center. If one week passes, I understand that the center will assume I no longer need their services.
- If I "no-show" for two appointments in one quarter, I understand that I will not be able to use the Counseling Center's services until the following quarter. I also understand that if I request counseling the following quarter, assignment to the waiting list may occur if immediate assignment to my counselor is not possible.
- If I cancel two appointments in one quarter I understand my counselor will review my case for continued eligibility, I may or may not be eligible to continue based on the review.
- If I intend to continue counseling after a quarter break I agree to notify the Counseling Center of my intent to continue services no later than the 5th day of the quarter.
- It is my responsibility to notify the Counseling Center if my contact information changes.
- I understand that if I am waiting to be assigned to a counselor, two attempts to reach me will be made. If messages can be left, I have 2 business days from the delivery of the second message to contact the center.
- If I have designated that messages cannot be left, it is my responsibility to check back with the Counseling Center (by phone or in person) on a weekly basis until I am assigned to a counselor.
- If I am on the waiting list and expect to be out of town, I will notify the Counseling Center.
- I will notify the Counseling Center if I no longer need or want their services.
- I understand the above information, and have received my own copy of this form for my review.
Client Signature: ___________________________________ Date: ____________________________
I have asked to be contacted by email and I understand that the confidentiality of information transmitted via email cannot be guaranteed. Client initial here: ___________
Counselor Signature: _____________________________ Date: ______________________________