WSFCS Schools Informed Consent Form

WELCOME: HOPE Counseling & Consulting offers a wide range of services to students, addressing concerns in the areas of personal development, mental health, cultural issues, life planning, stress management and achievement of educational goals. Services are provided by licensed clinicians and supervised interns.

SCOPE OF PRACTICE: HOPE works within a short-term counseling framework and offers individual therapy to students within the school setting. You and your counselor will meet to determine the best services to fit your student’s needs. Each student will receive at least ten sessions during school hours either once a week or every other week. Should your student need more than ten sessions, you will be notified. Parent and caregivers will contribute to the care of their minor children. Counselors will communicate with families to keep them informed of their students’ progress. *Please note, that students referred that are in kindergarten , through second grade will receive services that include the students’ parents and/or caregivers. This means that services will be arranged according to parent/caregivers schedule and could possibly be outside of school hours. HOPE has offices located in Winston-Salem, Reidsville, Dobson, Thomasville, and King.

CONFIDENTIALITY: Confidentiality will be in keeping with the ethical standards of the American Counseling Association, HIPPA, and other federal and state laws. Be aware that your official diagnosis is a permanent part of your counseling records. Counseling data/records will be confidential except in the following cases:

1. Client/guardian’s written consent to disclose
2. Awareness of child or elder abuse
3. Awareness that a client is a danger to self or other
4. Court-ordered disclosure
5. Information required for a payment and/or additional counseling session from insurance or EAP
6. Crisis at your student’s school requiring police and/or medical personnel.

HOPE coordinates care with the Guidance Counselor at your student’s school on a need to-know basis.
HOPE uses electronic data storage and fax machines. Client records are accessible only to HOPE staff and only on a need-to-know basis. All electronic records are subject to confidentiality restrictions. No record of a student using HOPE services is kept in their official school records, placement file, or on their official transcript.

COST FOR SERVICES: HOPE Counseling and Consulting is happy to file your students’ session fees to your insurance company. Please note, it is your responsibility to make sure your deductible has been met and that your plan covers mental health services for your child. Counseling sessions for students are 30 minutes long and cost $60 per session. Currently, HOPE can take most insurance plans except for Medcost.

RISKS AND BENEFITS: Receiving counseling entails risks and benefits. Counseling may involve the risk of remembering unpleasant events and may arouse strong emotions. The benefits from counseling may allow the student to better cope with relationships and gain a better understanding of themselves, their values, and their goals. This may lead to greater personal growth.

YOUR RIGHTS: You have the right to competent and professional services that includes an explanation of diagnoses and recommendations for treatment. You have the right to be treated with respect at HOPE. You have the right to a therapeutic relationship without physical, sexual, verbal, or other abuse or exploitation. You have the right to file a complaint. You have the right to evaluate our services. You have the right to request to review or release your clinical file. Relationship therapy files belong to all members of the relationship. Therefore, we will need all parties to sign a release of information before any information from the file is released to a member of the relationship or to a third party.

YOUR RESPONSIBILITIES: You are responsible to be an active and collaborative participant in your experience at HOPE. Students are expected to demonstrate respect for their counselor and to be honest in their communication. This allows the HOPE counselor to best assist your needs and to be responsive of your requests. Please communicate your needs with your counselor in a timely manner.

I/We have read and understand the contents of this informed consent and give HOPE Counseling & Consulting permission to provide services for my/our student(s):

Student(s) Name:  

School Student(s) Attend:  

September 26, 2022

 

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Signature Certificate
Document name: WSFCS Schools Informed Consent
lock iconUnique Document ID: bb41c20a628f2d1aad143f3e0ecba06484b80bf0
Timestamp Audit
September 14, 2022 8:49 pm GMTWSFCS Schools Informed Consent Uploaded by Linda McRae - info@thereishopeinc.com IP 180.190.192.104
September 15, 2022 3:55 pm GMTThere is Hope inc - info@thereishopeinc.com added by Linda McRae - info@thereishopeinc.com as a CC'd Recipient Ip: 180.190.192.104