North Carolina Agricultural and Technical State University
Counseling Services
POLICIES AND PROCEDURES
TABLE OF CONTENTS
SECTION
SECTION
SECTION
SECTION
1:
2:
3:
4:
MISSION STATEMENT
OBJECTIVES AND GOALS
ADMINISTRATIVE ORGANIZATION
GENERAL OFFICE PROCEDURES
Hours of Service
Attendance
Scheduling and Recording Leave
Emergency Coverage
Employee Work Planning and Performance Management
Telephone Procedures
Use of Phone
Office Dress Code
SECTION 5:
SECTION 6:
ETHICAL PRACTICE
INDIVIDUAL SERVICES
Eligibility for Services
Faculty and Staff Eligibility
Initial Appointments
Intake Procedures
Delivery of Individual Services
Termination of Counseling
SECTION 7
SECTION
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SECTION
9
CLIENT RECORDS
Maintaining Records
Confidentiality of Client Records
Disclosure of Confidential Information without Prior Consent
Release of Confidential Information to Students
Disclosure of Confidential Information to Third Parties
Disclosure Pursuant to Judicial Order
Disclosure for Research Purposes
UNIVERSITY WITHDRAWAL PROCEDURES
Regular Withdrawal
Regular Administrative Withdrawal
Retroactive Withdrawal
COUNSELING SERVICES: CLINICAL AND
PROFESSIONAL SERVICES
Academic Counseling, Information and Regulations
Testing
Career Counseling
Changing a Major
Personal Counseling
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Individual Counseling
Group Counseling
Group Services
New Student Orientation
New Student Informational/Freshman Interview Program
Drug/Alcohol Groups
Personal Growth Programs
SECTION 10:
SPECIAL TREATMENT ISSUES
Hospitalization
Mobile Crisis Team
Voluntary Hospitalization
Procedures for Voluntary Hospitalization
Involuntary Hospitalization
Procedures for Involuntary Hospitalization
Student Return to the University After Psychiatric Hospitalization
Procedure to File Commitment
Mental Health Student Conference
Child Abuse Reporting
Elder Abuse Reporting
Responding to a Subpoena
Missing Persons Procedures
Service Animals
SECTION 11:
SECTION 12:
TESTING SERVICES
CONSULTATION SERVICES
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SECTION 16:
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Overview
Placement
Goals and Objectives
Counseling Skills
Assessment Skills
Outreach
Professional Development
Trainees’ Rights and Responsibilities
Reasonable Accommodation
Trainee Affirmation of Confidentiality
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APPENDICES
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Consultation
SECTION
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STAFF DEVELOPMENT
RESEARCH
QUALITY ASSURANCE
ANNUAL REPORT
Internship Program
1.
2.
3.
4.
5.
6.
Request for Leave
Consent to Release/Exchange Information
Rights and Responsibilities of Students Using Counseling Services
Student Referral Form Information on Group Counseling
Group Interest Form
Intake Form
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Section 504 of the Federal Rehabilitation Act of 1973
Addictive Behaviors Assessment
Client Satisfaction Survey
Practicum/Internship Form
Counseling Services Training Program for Master’s and Doctoral Students in Mental
Health Professions
Internship/Practicum/Shadow Graduate Student Confidentiality Form
Dear Prospective Trainee letter to applicants
Graduate Student Shadowing Experience Attendance Roster
Minor Consent Form
Letter to parent re: minor student
Approved abbreviations for notes
Outreach Request Form
Sign In Sheet
Emergency Manual Counseling Services
North Carolina Agricultural and Technical State University
Counseling Services
POLICIES AND PROCEDURES
1.
MISSION STATEMENT
The purpose of Counseling Services is to assist students in accomplishing their personal, academic and career
goals through counseling, testing and enrichment programs. To accomplish its mission, Counseling Services has
developed set of goals that are consistent with the mission of the University and the goals of the Student Affairs
Division.
2.
OBJECTIVES AND GOALS
Provide high quality individual and group counseling services to students who may be experiencing
psychological, academic, career or behavioral difficulties.
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New students are contacted by Counseling Services by September 30th of each year to inform about
services and upcoming significant dates.
Academic/career/personal counseling sessions are conducted with students on a daily basis.
Provide programming focused on the developmental needs of students to maximize the students’ potential to
benefit from the academic environment.
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Conduct four (4) one-half day life skills seminars during the academic year.
Serve as liaisons to Housing and Residence Life and Academic Departments.
Provide testing and evaluative assessment services to help foster student self-understanding and decisionmaking.
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Plan a calendar of all testing programs indicating proctors by September l of each academic year.
Inform students with learning difficulties about services available to them for accommodations.
Provide professional development opportunities for staff including in-service training programs, workshops and
other continuing education activities.
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Staff is to attend at least one professional meeting, workshop or seminar for self-enrichment.
Hold weekly staff meetings.
Plan at least one In-Service Training Conference monthly during academic year. Provide consultative
services to the Institution to make the environment as beneficial as possible to the intellectual, emotional
and physical development of students.
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Counselors conduct consultation sessions with departments/etc. each year (ex. Study Skills, Time
Management, and other Special Programs).
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Counselors provide training to the institution training on mental health issues impacting university
community.
Conduct research, planning and training programs that will be responsive to internal as well as external needs of
the university campus.
 All outreach programs are evaluated after each presentation; and each revised or eliminated each academic
year.
 Present at professional conferences.
The counseling staff functions in accordance with the highest ethical standards.
 Situations presenting ethical issues or dilemmas are reviewed carefully, occasionally involving outside
consultation.
 Ethical issues are resolved in accordance with State and Federal Statutes and relevant recognized
professional ethics
3. ADMINISTRATIVE ORGANIZATION
The organizational components include the Vice Chancellor for Student Affairs who is the governing and
administrative authority for all aspects of Student Services and the Director of Counseling Services who is
responsible for the direct administration, clinical component, supervision and coordination of all counseling
services and programs. Other responsibilities of the Director include selecting and supervising the following
professional student affairs personnel to assist with the planning, organization, implementation of programs and
services, and clinical services.
The Assistant Director is responsible for assisting in the management, coordination and supervision of
Counseling Services functions, programs and services, and clinical services.
Clinical staff are responsible for providing counseling which includes: personal, academic, educational, and
career counseling and assessments and appraisals for individual analysis.
All clinical staff assist with administrative staff responsibilities when it is necessary for the smooth operation of
Counseling Services
Administrative staff responsibilities include but are not limited to assisting with phone, ordering supplies,
maintaining inventory, handling cash and deposits, creating and maintaining files and records, scheduling,
greeting those who enter the office, maintaining a professional atmosphere and office appearance.
4.
GENERAL OFFICE PROCEDURES
Hours of Service
Counselors are available to see students during the hours of 8:00 a.m. to 5:00 p.m., Monday through Friday.
Information about Counseling Services is available 24/7 on the Counseling Service’s Website
(http://www.ncat.edu/student-affairs/student-services/counseling/).
Attendance
All staff members are encouraged to inform the receptionist or Counselor on Duty (COD) when they leave the
office area. Staff who will be late or absent from work, will call the office within a half-hour following his/her
designated arrival time.
In addition to calling into the front desk, staff will call, text, or email all absences to the director and/or the
assistant director, if one is on travel.
For all leave or absences from the office, approval will be obtained from the Director or in her absence the
Assistant Director or designee. In addition, the Receptionist will be notified. If the Director, Assistant Director
or designee are away from the office, and the leave constitutes an emergency, the receptionist or a counselor is
notified.
If it is necessary for a staff member to alter the time when they will not be available to provide other
services, such as ongoing group times, lunch break or regular consultations staff will inform the director /
assistant director to assure the change will not negatively impact Counseling Services’ operations.
Scheduling and Recording Leave
Leave may be taken (if possible) when it will least interfere with the efficient operation of the Office. The
employee will submit the Request for Leave Form PD-109 (see appendix) and have it approved in advance by
the Director.
Individual leave records will be recorded on the Employee Leave Record forms found in Banner and submitted
monthly.
Emergency Coverage
During daytime business hours, the Director, Assistant Director, or a counselor will respond to an emergency
situation. After hours, the Director and the Assistant Director are available for emergency response.
Employee Work Planning and Performance Management
In accordance with State policy, the Director will establish and maintain an annual work and performance
management plan for each employee under her supervision. This is a mandatory program for all employees as
directed by the State Personnel Commission.
Front Desk Procedures
Front desk staff provide professional services and creating a welcoming environment for our consumers.
Common duties and responsibilities include
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Log into Titanium and keep open while at front desk
Check Counselor on Duty (COD) Schedule
Check to see who is absent
If clinician calls in sick, please ask COD to reschedule appointments
Speak clearly and listen carefully in order to best serve caller
Do not leave front desk unattended to look for staff
Keep conversations to a minimum when at desk
When a new student enters, please contact COD to determine appropriated paperwork
COD will inform front staff which clinician (COD/Intern) will see student / consumer
Remember, Interns are training professionals and will consult with supervisors as needed
Telephone Procedures
The appropriate procedures for answering the telephone are listed below for your convenience. Answer by
saying “Counseling Services, this is [your name]. How may I help you?”
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Always answer the telephone in a polite and courteous voice.
The telephone should be answered by the second ring.
Keep a positive tone in your voice.
If caller is to be placed on hold, inform caller they will be placed on hold.
If caller is on hold for 60 seconds, check back on them and let them know you are still assisting them.
If caller is kept on hold for longer than two minutes, check back and ask caller if they want to continue to
hold or if they prefer being called back.
If caller needs to be assisted by another department, provide caller with the appropriate department
telephone number and inform the caller that you will transfer them to the appropriate department (where
possible)
Staff will take and deliver accurate messages.
Use of Phone
All staff members are expected to limit personal phone calls to those which are essential to completing their job
requirements. Any personal long distance calls should be charged to a phone card or made from a personal cell
phone. Should emergency circumstances arise which necessitate a personal long distance phone call, staff
should notify the Director/Assistant Director and make arrangements to reimburse the State. An itemized phone
bill for each phone line in the Counseling Center is obtained each month from the Telecommunications
Department of the University.
Office Dress Code
Although there is not a standard office dress code, professionalism will be taken into consideration when
preparing for work. Overall hygiene is very important, with good grooming as the finishing touch. Appropriate
dress suitable for a professional office setting is also highly recommended. Each staff member is encouraged to
project a professional image that will reflect favorably on the Office of Counseling Services as well as the
University.
5.
ETHICAL PRACTICE
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Counselors may engage in limited private counseling practice that does not interfere with meeting obligations to
the University. Counselors may not see North Carolina A&T currently enrolled students in their private
practice. As part of that practice, counselors do not seek to limit, decrease or extinguish campus counseling
services for the benefit of the private counseling practice and likewise, counselors do not use their employment
to gain favors or special treatment for their private practices.
Counselors do not conduct private practice during their employment hours or conduct private counseling
sessions with private clients in the campus office facilities, or use campus equipment in counseling private
clients. Counselors never allow their private counseling duties to conflict with or prevent full discharge of
responsibilities as University employees.
The Counseling Services’ staff affirms and supports policies regarding affirmative action, sexual harassment,
and grievance procedures. The Counseling Services’ staff does not discriminate against clients on the basis of
race, color, religion, marital status, national origin, ancestry, sex, sexual orientation, physical or mental
handicap, medical condition, status as a veteran or disabled veteran, age, or citizenship.
Counseling Services Staff operate within the Ethics of North Carolina A&T State University and the ethics of
their profession.
6.
INDIVIDUAL SERVICES
Eligibility for Services
Counseling Services offers a variety of services to help all currently enrolled North Carolina A&T State
University students address challenges and difficulties they may face. Our services are designed to help students
understand themselves better, create and maintain healthy relationships, improve their academic performance
and make satisfying career and life choices. All enrolled students who are taking at least one class on campus
are entitled to one session, at which point we will determine whether or not their needs can be met in our
system. Students who are exclusively distance learning and have not paid a student fee are not eligible for
services We are dedicated to helping our students by providing brief counseling from a wide spectrum of
services. Those include individual and group counseling, outreach and consultation, training and supervision,
teaching, psychological testing, and research. If more intensive or specialized care is needed, we will assist with
making referrals to healthcare providers in the community.
Some of the issues that are commonly addressed through referral to services outside of the Counseling Center
include:
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A desire to be seen more than once a week or for long-term therapy, or a need for such as
indicated by:
 History of multiple hospitalizations
 Chronic suicidality and/or self-injurious behaviors; history of repeated suicide attempts
 Indication that short-term therapy may be detrimental or non-beneficial
 Evidence or risk of progressive deterioration in mental or emotional functioning, requiring
intensive intervention
 Manifestations of psychotic symptoms without willingness to remain on medication for
stabilization of symptoms
 Inability or unwillingness to provide the necessary information to thoroughly assess
symptoms
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Students who need specialized services not available through the Counseling Center as indicated
by:
 Presence of significant drug and/or alcohol problems such substance dependence, primary
substance abuse, and/or past failed treatments
 Presence of significant or long-standing eating disorder with no period of remission, no
previous treatment, or that may pose a medical danger
 Request for psychological evaluation for the purpose employment clearance or other
nonacademic purpose
 Services to fulfill students' court-mandated assessment or treatment requirements
With a signed consent form (see appendix), family members of currently enrolled NC A&T’s students are
eligible for a 1-2 time family consultation(s) with the student when the rendering of such service is
advantageous to the welfare of the student. The family member(s) are not eligible for individual or couple
counseling, but may meet with a counselor for purposes of obtaining a referral.
For reasons of professional responsibility, in the case of students who have just separated from the University,
eligibility may be extended for no more than three (3) sessions. Any such extensions of eligibility must be
clearly justified.
Faculty and Staff Eligibility:
Counseling Services is designed for use by NC A&T SU students, however there are situations when faculty
and staff usage is appropriate.
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Faculty and staff may consult with or be consulted by the counseling staff regarding generalized
student concerns or specific situations involving students (subject to the policy on confidentiality).
Faculty and staff may be seen on an emergency basis for one interview for personal crisis
intervention or consultation, or referral to community resources.
General Public Eligibility
Inquiries and requests for service made by the general public usually come by telephone. Such calls are handled
carefully as a public service, and for the sake of positive public relations. Callers are usually directed to
appropriate agencies or other community referrals. On occasion, as dictated by humanitarian aims and
professional ethics, a staff member may offer a consultation to a non-eligible person who is in crisis and
distress, with the goal of assisting for an appropriate referral to community resources. This very infrequent
situation may occur when a confused and distressed person suddenly appears or telephones for help.
Appointments
Established students usually schedule appointments in advance by visiting or telephoning Counseling Services.
Walk-in and emergency appointments are also available. For initial appointments students are requested to read
the Confidentiality/Rights and Responsibilities Information and complete the Intake Form (See Appendix).
Intake Procedures
The receptionist will assist walk-in students.
 When students arrive at the office requesting services, the receptionist will enquire about the students
service need (e.g. testing, withdrawal, counseling) and inform the counselor-on-duty (COD) of the
student’s service request. Students will be asked to complete the required intake paperwork.
 When the intake paperwork is complete, the receptionist will give the completed paperwork to the COD
(see Maintaining Records for information on paperwork).
 The COD will meet with the student to determine the student’s needs, and if crisis intervention is
indicated. If crisis intervention is not indicated the student is scheduled for an intake session.
Delivery of Individual Services
Students are not charged fees when they are counseled, there may be fees associated with certain forms of
testing.
If the student requests to see a specific counselor, that request will be honored to the extent possible within
scheduling limitations.
Students who are referred, or who walk-in on an emergency basis, will be seen immediately by the COD or first
available counselor. The Director/Assistant Director may be consulted in determining a course of action.
If the student has had one or more sessions with a counselor and requests a different therapist, the counselor will
attempt to determine the reason for the request. The request is typically granted. On some occasions a student
may be put on the schedule of a counselor different than their established therapist by administrative staff. If
this occurs, the new therapist will attempt to determine the reason for the requested and if appropriate will
initiate the transfer. If the student requests another transfer within a few sessions the student should meet with
the Director/Assistant Director before a third transfer is initiated. The purpose of this meeting is to determine if
it is likely that the student may benefit from seeing a new therapist. Therapists may also present student
requesting a transfer.
If a counselor determines that a psychiatric evaluation, medical evaluation or consultation is indicated, the
counselor will consult with colleagues or the Director/Assistant Director and make appropriate referrals to
Sebastian Student Health Center or other psychiatric facility.
If a counselor determines that a student needs services not provided by the University, it is incumbent upon the
counselor to locate the appropriate service provider in the community and make a referral. Efforts may be taken
to make sure that the student makes contact with the referral agency.
Counseling Services Staff document referrals using the Student Referral Form (See Appendix)
Assessment of Benefit
Part of the intake process involves the administration of the Counseling Center Assessment of Psychological
Symptoms (CCAPS). This instrument measures student’s level of distress across multiple dimensions and
compares this with other students who are seeking services at counseling centers. The CCAPS is readministered after the third session in order to assess the benefit students are receiving from therapy.
Counselor Safety
Counselors are provided with a “panic button.” This button is to be used if the counselor believes he or she is in
danger and there appears no other way to notify staff of the situation. This button triggers a silent alarm with
campus police.
Panic Button Procedures and Guidelines
Duress alarms are carried by all clinical staff and are mounted to the receptionist desk It is important you carry your alarm with you
whenever using other office spaces.
If the alarm is pressed Campus Police will be immediately notified and will respond.
IMPORTANT: Under no circumstances should anyone working at CS attempt to physically intervene with a student who might be
dangerous. We are not trained for such actions, and we are likely to make the situation worse if we do try to intervene. The Duress
Alarm notifies the police; it is their responsibility to make the direct intervention.
1.
When to use the Duress Alarm: whenever you believe immediate police intervention is necessary
a) your physical safety is in danger
b) your client has already harmed himself
c) you overhear or otherwise learn that someone else on site is in danger/at risk
d) in the event of a medical emergency (e.g., collapse, heart attack, seizure, etc.)
e) a potentially dangerous person takes flight
2.
Roles and Responsibilities When An Alarm Is Triggered
a) Front Desk
i) Once the duress alarm is triggered, the Police will be on their way.
You must be ready for their arrival with the following information:
(1) Which room?
(2) Name of Client?
(3) Make sure that the entry to the unit is clear (instruct people to move out of the doorway etc.)
ii) Contact University Police by phone to verify that the Duress Alarm has been received and inform the Dispatcher of any
pertinent information: Screams or other noises coming from the area, Gunshots, Injuries, Direction of Flight etc.
iii) Notify all of the following, whether or not they are on-site: Dr. Barnette, Chief Newell, & Dr. Pierce. Inform them
which office/who has sounded the alarm.
iv) If the above people are not available, notify available UPD, Dr. Rashid and Mrs. Kim Sowell
Carry out any other instructions given to you by the staff.
b) Staff
i) The senior-most staff person who is on-site, or his/her on-site designee, will be in charge of the incident, until arrival of
the Police.
ii) Someone must contact the office in question by phone to assess the situation, if possible. Please be aware that it is
possible that the counselor will not be able to answer the phone.
Yes/No questions to ask:
(1) “Is there a weapon involved?”
(2) “Is anyone injured”
(3) “Do you want a staff member to enter now”
(4) “Should we wait for police?”
(5) Entering the room?
(a) The senior-most staff person who is on-site will make the decision to enter or not to enter based on the totality
of the situation, remembering that CS staff members are not trained for intervention with potentially violent
individuals, and they may make the situation worse if they do try to intervene in those circumstances. If there is
no contact made with the counselor in the room NO ONE WILL ENTER THE ROOM UNTIL THE POLICE
ARRIVE. If there are any indications of violence occurring in the room then the rest of the unit will be
evacuated.
iii) A staff member should look up the client in Titanium to see if there are any instructions or crisis plans in place. If there
are specific instructions or crisis plans in place, that information must be available to the Police officers responding.
iv) Someone needs to be at the front door to direct UPD, and provide additional information if we have any. Must have basic
information for the arriving police officers: Which room? Name of Client? Also the Front Desk Personnel should make
sure that the entry to the unit is clear (instruct people to move out of the doorway etc.)
v) Two staff members should be available by the door of the office in case they are needed.
c)
3.
Trainees and others
i) Be aware of the location of the duress alarm in the office/interview room you are using. The duress alarms in the
interview rooms are in the same spot: clipped to the tray on the table.
ii) Trainees should not be expected to intervene in these situations.
iii) The hallways should be kept clear.
After the Event
a) Debriefing with all those involved should occur as needed as soon as possible following the event. Additional debriefing with
entire CS staff should also be considered. University Police Supervisory staff from the incident should probably be included
in this de-briefing. (Consider having A&T’s EAP or UNC-G Counseling Center do the debriefing rather than doing it
ourselves since we were involved).
b) Accurate information should be distributed to all CS personnel as soon as possible. Control of rumor and misinformation is
important.
c) An incident review should be conducted by the Administrative Team (Pierce, Barnette, Rashid, Newell, Williams (legal).
4.
Additional Things To Consider
a) Keep your office door UNLOCKED when with a client. Police officers need to be able to gain access to your room.
b) There is a 2-second delay before the duress alarm is activated. This is to minimize accidental presses of the button. You need
to hold the button down for two seconds before it is activated.
c) Tips for dealing with potentially dangerous person:
i) put or keep something between you and the individual
ii) try to position yourself closest to the door
iii if the potentially violent person attempts to flee, do not put yourself in harm’s way; get a description and direction of
travel and inform the appropriate authorities
Termination of Counseling
Services may be terminated for the following reasons:
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Student’s need cannot be met by existing services. In such cases, every effort will be made to provide
appropriate referral.
Student meets the criteria described in issues that are commonly addressed through referral to services
outside of the counseling center listed above.
Student has used services to the limits as currently structured, 20 or less sessions during the academic year.
In such cases there should be a consultation with the Director.
If a student has failed to attend two scheduled appointments without appropriate notification in a single
semester, the student will be ineligible for scheduled therapy for the remainder of that semester. The
student is still eligible for crisis services. Counseling services can be reinstituted the following semester
once the student has discussed the missed appointments with his/her counselor and a clear commitment to
attending additional sessions have been established.
Student is concurrently in treatment with another mental health provider, and efforts to coordinate
treatment are not successful.
Termination Practices
A termination note is drafted for each student who has been scheduled for an intake, completed more than two
academic or career counseling sessions, and/or initiated the learning disability assessment process. At the time
of termination, a student is removed from the assigned counselor’s case load and is removed from the roster of
active clients in Titanium Schedule, the center’s electronic health records software. Completion of a termination
note and delisting as an active client may take place immediately upon the decision to discontinue counseling or
may be postponed until the end of the current semester. All students who were not assigned to a counselor’s
caseload, but were nonetheless served (i.e., had only phone/e-mail, screening, consultation, or withdrawal
appointments) are delisted as active clients at the end of each semester by the Titanium administrator.
Students who have committed to returning for sessions in the following semester may remain on the list of
active clients. Should the student not return for additional sessions, the file will be closed.
7.
CLIENT RECORDS
Maintaining Records
Client Files
A file is created for all students seen for an intake interview for the following reasons:
1. Individual counseling (academic, career, personal, life skills/personal growth)
2. Psychological Testing and assessment services
3. Group Counseling
4. Client Consultation Record
A file will not be generated for students seeking Withdrawal services. Withdrawal services are the responsibility
of the Registrar's office, however; Counseling Services staff may choose to help with this process if a student
has been referred to Counseling Services erroneously. The Withdrawal process is considered an administrative
procedure, not a counseling procedure. A copy of the Official Student Withdrawal Form is made if Counseling
Services is involved with the withdrawal process. A copy of the Withdrawal Form is kept for ten (10) years as
record of the withdrawal after the withdrawal has been completed and processed.
At times, a student may be seeking counseling during the withdrawal process. Under these circumstances, the
withdrawal process is considered a counseling session. A session note is generated and a file is created. A copy
of the Withdrawal Form is included in the file.
Filing Procedures
All personal client files should be kept in the central filing cabinet located in the main office. Files or any
materials that belong in the files are not to be removed from campus. Files are locked at the end of the work day
and over weekends.
Electronic File ContentsWhen students are seeking counseling services (personal, academic, career, etc.), the electronic record will
contain the following forms:
 Client Demographics
 Screening Form
 Diagnosis
 Mental Status Evaluation and Report
 Checklist of Suicide Risk Factors, Suicide Risk Assessment Summary
 Chemical Uses Care Formulation
 Correspondence
 Progress Notes
 Consent to Release/Exchange Information
 Termination Summary
Non-client consultation notes are also filed electronically.
*Contact list is generated by Titanium. All forms are provided in Titanium.
Confidentiality of Client Records
This policy follows and is subject to the general University Policy.
Records are collected and maintained to aid in serving clients, while at the same time protecting clients’ privacy
and fulfilling the professional responsibilities of confidentiality. No information is a matter of public record,
including the names of clients utilizing counseling services. Official records of the service may include the
following information:
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Appointment records for individual, couple, and group sessions
Demographic data supplied by the client on the Personal Data Form
Intake assessment provided by the counselor on the Intake Report
Summary notes of each client contact, dated and signed by the counselor
Any release of information signed by the client and copies of correspondence pursuant to that release of
information
Copies of any correspondence with or about the client
Any document required by law
Counseling services are confidential, in keeping with State and Federal laws and the ethics of their profession.
No information is released to outside parties without the client’s written consent, except as noted in the
Disclosure of Confidential Information without Consent section below.
All persons using Counseling Services are advised in writing of the specific legal limits of confidentiality.
A confidential clinical record documenting the student’s treatment is kept for a period of ten (10) years after
treatment has terminated. ACA, NASW, and APA guidelines are followed for documenting clinical notes.
Disclosure of Confidential Information without Prior Consent
Information may be released from client records to appropriate persons in connection with an emergency if the
knowledge of such information is necessary to protect the health and safety of a client or other persons.
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Counselors have a legal responsibility (Tarasoff vs. Regents of the University of California) to follow
procedures for dealing with potentially violent behavior on the part of the client.
Counselors have an ethical responsibility to follow procedures for dealing with potentially suicidal
behavior on the part of the client.
Counselors have a legal responsibility to report to the local police authority and juvenile police authority or
to the county child protective services, any cases of child abuse reported by clients.
Counselors have a legal responsibility to report suspected dependent adult or elder abuse.
The guidelines for releasing information under these special circumstances are outlined in Section 8
“Special Treatment Issues”.
Release of Confidential Information to Students
Client access to records:
Within a period of five (5) working days following receipt of a client’s written request, the client may inspect or
obtain copies of his or her official record unless it is determined that there could be a substantial risk of
significant adverse consequences if the client has access to the record or specific portions of the record.
Disclosure of Confidential Information to Third Parties
Consent to Release/Obtain Information Form is provided for clients requesting release of information gathered
in the course of counseling to other appropriate mental health professionals. The form is valid for a maximum
of one year from the date signed and includes:
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The individual or agency to who the information is to be made available.
The data or information to be released.
The client’s signature. (Telephone requests for release of data will not be honored; however, email requests
from students will be honored).
Disclosure Pursuant to Judicial Order
Confidential information may be released if properly subpoenaed pursuant to a judicial proceeding. In such
proceedings, the University notifies the student prior to compliance. Every effort will be made to retain the
confidentiality of records in the client’s best interest.
Disclosure for Research Purposes
Students participating in research studies conducted by Counseling Services will be informed of the safeguards
against disclosure in the research design. Research studies of this nature demand proper student knowledge and
consent.
8.
UNIVERSITY WITHDRAWAL PROCEDURE
Withdrawal services are the responsibility of the Registrar’s office
9.
COUNSELING SERVICES: CLINICAL AND PROFESSIONAL SERVICES
Academic Counseling, Information and Regulations
Academic counseling is provided to students who report that they cannot concentrate, do not know how to
study, are failing courses, have poor academic averages and seek assistance in discovering and overcoming the
causes of such difficulties. Clinical Counselors in the office of Counseling Services will provide academic
skills training.
Testing
Course credit may be granted for the successful completion of standardized tests under the College Level
Examination Program (CLEP), as approved for specific courses by University departments. Fees for CLEP and
other standardized examinations are determined externally, rather than by the University, however a Counseling
Services Examination Fee is assessed by Counseling Services. These credits are treated as transfer credits.
Those who wish to take the CLEP complete the CLEP registration process as outlined on the test publisher’s
web site, http://www.clep.rog. Administration and proctoring at Counseling Services is secured by submitting
the CLEP Registration and Information sheet available on the Counseling Services web site or at the Counseling
Services Office and payment of a non-refundable Counseling Services Examination Fee at the university
Cashier’s office before the appointment is scheduled. The Counseling Services Examination Fee may be
transferred to a future CLEP administration if the scheduled individual notifies Counseling Services at least two
days in advance and schedules another exam at that time. Questions about the program may be addressed to the
Office of Admissions or the Office of Counseling Services.
Learning disability and ADHD assessment are conducted to determine if specific learning disability(ies) and or
attention impairment warrant special attention or accommodation.
Career Counseling
Career counseling is available to students who wish to appraise their talents and interests and to select a
program of study or major appropriate to their career or personal objectives. Clinical Counselors assist students
in choosing an appropriate major, changing majors, and finding occupational information related to the major
through utilization of interest inventories, and printed and computer materials, to assess interests, values and
aptitudes.
Changing a Major
Counseling Services can offer students assistance by administering a career Interest Inventory to identify career
interests and discussing the reasons for the switch in majors, i.e., the student’s strengths and weaknesses, longrange goals, desired standard of living concerns, such as job location, etc..
Personal Counseling
Personal counseling is available to students who have personal concerns and emotional difficulties that may
interfere with effective learning. Counseling Services provides a safe, confidential environment where students
can explore issues of concern, gain awareness and insight, and become increasingly active in taking charge of
their life.
Individual Counseling
Individual counseling is the core component of the Office of Counseling Services. Most students require only
short-term counseling (5-7 sessions), but others continue for long-term therapy. The availability of long term
therapy will be determined by therapist/student based on need and resources.
Group Counseling
When several students present similar concerns, a counselor may choose the group approach. Group counseling
is provided on an ongoing basis with groups being formed as needed (see appendix for Group Interest Form and
information on Group Counseling).
Group Services
New Student Orientation
New student orientation provides services and assistance which aid new students in their transition to the
University, expose new students to the broad educational opportunities of the University, and integrate new
students into the life of the University. The Vice Chancellor for Enrollment Management, who is responsible for
Orientation, designates the Director of Orientation, to plan and coordinate the Orientation Program and appoints
an Orientation Committee, inclusive of staff from Counseling Services, to assist in the implementation and
evaluation of the Orientation Program.
In addition to the Orientation Program conducted at the beginning of the fall semester, the University offers
Summer Orientation Programs. The advantages of attending summer orientation are many. Counseling Services
provides an overview of services and informational brochures. Students can meet faculty persons who will help
them select courses, register for classes prior to fall, discuss financial aid matters and pay fees.
New Student Informational Session
New freshman students face a variety of challenges during the first year. In an effort to help these students make
the transition to college, counselors schedule personal information sessions with the students to assess their
adjustment to college life.
Drug/Alcohol Groups
Drug/Alcohol Groups are offered periodically. The Drug/Alcohol Program focuses on four components:
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Orienting members to the group (see Appendix)
Assessing level of usage and potential for addiction (see Appendix).
Providing education on the physical and mental effects of the substance.
Recognizing and preventing potential addiction.
Creating awareness of available rehabilitative services.
Making Referrals to outside providers for treatment as needed (see Appendix)
Professional standards of confidentiality are observed.
Personal Growth Programs
Counseling Services sponsors four student seminars per year on developmental topics. This programming
requires that counselors leave their office to venture into the academic and student community to provide
relevant activities, programs and services to meet the needs of the student. Outreach programming consists of
personal growth seminars on topics such as: Skills for Student Success, Drug and Alcohol Issues, Relationships,
Skills for Career Success, Communication, Diversity, Domestic Violence, Sexual Assault Prevention, and
Time/Stress Management. Workshop topics are relative to national college trends.
In addition to student seminars, counselors conduct special workshops or presentations for campus and
community groups.
10. SPECIAL TREATMENT ISSUES
Counseling Services acts in accordance with Section 504 of the Federal Rehabilitation Act of 1973
(See Appendix)
Hospitalization
There are times when the treatment and/or level of care provided by Counseling Services are not sufficient to
meet the needs of our students. When students need a higher level of care than Counseling Services is able to
provide, having the student treated at an area hospital becomes a clinical consideration.
Cases in which Counseling Services may we may consider hospitalization include, but are not limited to:
1. A student is contemplating suicide or is threatening to seriously harm or kill self.
2. A student is presenting with delusional or psychotic thinking and is displaying behavior that is
grossly irrational or grossly inappropriate to the situation, or whose insight and judgment is impaired
to the point that he/she is unable to care for him/herself.
3. The student has threatened to kill or seriously harm another individual.
4. A student’s mental and/or emotional state has de-compensated to a point in which they are disabled
and poses a threat to functioning in their daily life.
Mobile Crisis Team
The Guilford-Sandhills Center for MH/DD/SAS: 910-673-9111 or 1-800-256-2452. Will go to meet with a person in the
community free of charge within a 2 hour window. Additionally, they will provide transportation to a hospital and do an
involuntary commitment,
Voluntary Hospitalization
When a counselor has a reasonable belief that a person is a danger to self or others or gravely disabled, and the
student is willing to be voluntarily admitted to a hospital, the counselor will assist the student in arranging for
appropriate hospitalization.
As a rule, Counseling Services discusses the option of inpatient hospitalization when a student reaches a
threshold in which the department is unable to provide an appropriate level of care and the student is believed to
be in danger of greater harm if the student does not receive a higher level of care. It is Counseling Services’
belief that individuals are left more empowered when they, and sometimes along with their families, make the
decision to admit themselves into a hospital. During these critical times, Counseling Services will often obtain
a release from the student and include families in the decision making process.
Procedures for Voluntary Hospitalization
1. If, in the clinician’s judgment, a student requires hospitalization for psychological reasons, immediately
consult with the Director of Counseling, the psychiatrist, or the Assistant Director. If neither of these
individuals is available, consult with another senior staff member for a consultation.
2. Attempt to gain agreement from the student that hospitalization is necessary and that the student is
willing to voluntarily go for assessment.
3. There are several steps taken in order to facilitate a student’s hospitalization. Moses Cone Hospital is
the local agency of choice for in-patient hospitalization. Moses Cone Hospital will assess the student as
well as secure a hospital bed.
a. Have student complete a Consent to Release/Exchange Information form, naming the Moses
Cone Hospital as the agency that is allowed to exchange release and exchange information.
Copy this form, keep the original and send a copy with the student.
b. Call Campus Police and request an officer be sent to transport a student to the Moses Cone
Hospital, unless family or friend is available to transport.
c. If the student has insurance, have the information ready for the Intake specialist at the Moses
Cone Hospital. If the student does not have insurance, inform the intake specialist.
d. Call the Moses Cone Hospital to notify them that we are sending a student for assessment and
provide information about the case.
4. Have Campus Police transport student to the Moses Cone Hospital.
5. Document event and include all discussions about options shared with the client, decision made based
on what information, notes regarding consultation, and contact with other agencies.
Involuntary Hospitalization
There are times when a student will decide not to admit him/herself, yet present an imminent threat to self or
others. That is, the student has made it clear that the student intends to commit suicide, commit homicide, or
engage in an activity that poses a threat of serious harm to self, others or the University facilities. During these
times, Counseling Services may make the clinical decision to involuntarily commit the student.
When a counselor has a reasonable belief that a person is a danger to self or others or is gravely disabled, and
that person is not willing to be voluntarily hospitalized, the counselor must initiate involuntary hospitalization
procedures for 72-hour treatment and evaluation. The counselor will first consult with the Director or Assistant
Director of Counseling Services. If the Director and Assistant Director are not on-site, contact with University
Psychiatrist for consultation will be attempted.
The process of involuntarily hospitalizing an individual is a serious matter, and the decision to initiate
involuntary hospitalization is made after careful consideration. This process involves the loss of civil freedom
and rights of the hospitalized individual. This process is always used as a last resort and only after all other
reasonable measures and steps have been taken and/or considered. Involuntary hospitalization is used only as a
means to preserve and protect a student’s life, the life of other individuals, or property.
N.C. General Statute 122C-262 permits, when a student is:
(1) mentally ill,
(2) dangerous to self or others AND
(3) requires immediate hospitalization to prevent harm to self or others, that student may be transported, without
a petition for commitment or a magistrate or court order, directly to a hospital to undergo an examination by a
physician or eligible psychologist. This emergency hospitalization option should be used only in clear cases of
the need for immediate action to prevent harm.
Procedures for Involuntary Hospitalization
In order to be involuntarily hospitalized, a student must be dangerous to self or dangerous to others.
1. Assessment
A) Client is assessed as being a danger to self or others.
B) Client is not able to commit to a written or verbal Crisis Response Plan or safety plan that the
Counseling Services therapist (in consultation with colleagues) believes would enable the client to
maintain safety.
C) Client does not agree to be transported to Moses Cone Behavioral Health, , Moses Cone Hospital
Emergency Department, or Wesley Long Hospital Emergency Department for assessment regarding
voluntary admission to an inpatient facility.
2. Actions (use as indicated during the assessment process)
A. Inform other Counseling Services therapists and front desk staff that the client is in crisis and safety
options are being developed, and enlist assistance to make phone calls or stay with the client as
indicated.
B. Call A&T University Police (phone - 336-334-7128). The University Police will come to our office
when called and help the client maintain safety (including preventing the client from leaving) while
safety options, including voluntary or involuntary hospitalization, are being developed.
C. If Step C under Assessment is reached; contact the Magistrate to initiate the Involuntary
Commitment Process.
1. Between 8:30 and 3:30 Monday-Friday, work with the Civil Magistrate in Greensboro.
Phone: 412-7855 OR 412-7862 Fax: 412-7856. Location: Guilford County Courthouse Room #214.
Directions from A&T: West on E Market toward N Laurel St. Market Street, Right becomes E
Friendly Ave.8 miles turn LEFT onto N Eugene Street. Courthouse (#201 S. Eugene St.) will be on
your left. Take a left into public parking lot (metered lot, bring quarters). Approach building from
the parking lot; go up the external stairs that start on S. Eugene St. side of parking lot, take left at top
of stairs into courtyard, then left into entrance of courthouse. You will go through security/metal
detectors. You have entered on main level. Magistrate’s office is on second floor, #214.
After 3:30 and on weekends, work with the Criminal Magistrate's office. Phone: 412-7879
Fax: 412-7871. Location: Lower level of the jailhouse, 401 W. Sycamore Street. This is the
building that contains the Sheriff’s Department; park in the same parking lot as stated above. Cross
S. Eugene St., Sycamore Street is across from Courthouse.
If the client is actually in High Point, call the High Point Magistrate's office.
2. Call the Magistrate's office to apprise them of the situation.
3. Fax or present in person to the Magistrate’s office:
a. A cover sheet, including the client's location in detail (required), and whether the client has any
weapons or (threatening) animals.
b. A completed Affidavit and Petition For Involuntary Commitment form.
Notarize the form here; the Magistrate's office does not do that.
If the person completing the form is a Licensed Psychologist (HSP-P) or a Physician (M.D.), and the form has
been notarized, the Affidavit and Petition form may be faxed to the appropriate Magistrate’s office (depending
on time of day). The Magistrate will then issue the Custody order and send out the Greensboro Police (if
student is within city limits) or the Sheriff’s Department (if in county limits). They may coordinate with the
A&T University Police, but the Custody order and transportation is ultimately up to the Magistrate’s discretion
and coordination.
If the criteria of an HSP-P or M.D. completing the form, and having the form notarized, are not met, do not fax
the form over. You must go to the Magistrate’s Office in person and dictate the form to them.
Individuals who are not an M.D., HSP-P (such as an MSW, MA, Ph.D. in Counseling, etc.), MUST go to the
Magistrate’s office in person and dictate to the Magistrate the Affidavit and Petition form. You may fill out the
Affidavit and Petition form at Counseling Services to use as a rough draft when you go to the Magistrate’s
office to assist with remembering pertinent information.
Forms are available in the folder file that contains the Emergency Operations Plan, and on the following web
site: www.nccourts.org
On www.nccourts.org website, go to Forms tab, then enter form # AOC-SP-300 to obtain electronic version of
Affidavit and Petition for Involuntary Commitment form that you can type up online and print out. Direct link
to this form is www.nccourts.org/Forms/Documents/661.pdf
4. When the Magistrate issues a Custody Order, the police will pick up the client and take him or her to The
Guilford Center for assessment and placement to a hospital bed. The Custody Order is valid for 24 hours and
then ceases to have effect. The Findings and Custody Order Involuntary Commitment Form, AOC-SO-302, can
be found on www.ncourts.org if you would like to review the form. We do not fill out this form, but you can
view it for informational purposes.
5. Call The Guilford Center Counselor to communicate our safety concerns about the student in detail and
answer questions to facilitate hospitalization. In addition, complete the Counseling Services Hospital Referral
Form.
24 hour Emergency number = 1-336-641-4993
24 hour Appointments number = 1-800-853-5163
Student return to the university after a psychiatric hospitalization
Upon return to the University after a voluntary or involuntary psychiatric hospitalization, the student may be
asked to attend a Mental Health Conference to discuss concerns about the student’s return
.
Mental Health Conference
1. The Director of Counseling Services and/or the University Psychiatrist may, based on their clinical
assessment, initiate a t Mental Health Conference. The focus of this conference will be to determine
if the student is ready and able to undertake the psychological, emotional, social and academic rigors
of the unstructured and sometimes stressful university environment. The conference will typically
include the Director of Counseling Services, the University Psychiatrist, the Dean of Students, and
the Director of Disability Services. The student may or may not be asked to be a part of this
conference.
2. The Dean of Students may require a student to participate in a Mental Health Conference when an
alleged violation of the Student Conduct Regulations (misconduct prohibited by the University) has
occurred in which the student demonstrates evidence of a physical and/or emotional condition which
would preclude an effective resolution of the situation through the judicial conduct process. Any
student who participates in a Mental Health Conduct Conference is entitled to the same rights and
has the same responsibilities as any other student who participates in any other judicial conference,
hearing or appeal. All university judicial procedures and guidelines apply to Mental Health Student
Conferences.
Once a determination is made by the Dean of Students (based on the incident report) to refer the
student to a Student Mental Health Conference, the conference will be scheduled with the student.
The Director of Counseling Services, the University Psychiatrist and the Director of Disability
Support Services, all of whom typically serve as hearing officers. The Dean of Students will preside
over the conference.
Counseling Services is informed about alleged violations of Conduct Violations by a sanction letter
sent from the Dean of Students Office. Information from the sanction letters is stored on Counseling
Services “P” drive.
If it is determined that the student accepts responsibility or is found responsible for the violation(s),
the Dean of Students in collaboration with the University Psychiatrist and or a representative from
Counseling Services will determine an appropriate intervention/sanction(s). The Dean of Students
may impose any sanction provided for in the Student Conduct Code. A student found responsible
for violating the Code of Student Conduct after a Student Mental Health Conference may appeal the
decision to the Vice Chancellor for Student Affairs in the same manner as provided in the Student
Conduct Code (see basis for Appeal and Appellate Procedures in Student Handbook).
Child Abuse Reporting
Counselors have a legal responsibility to follow these procedures when they become aware of child abuse. In
accordance with NC state law, a counselor who knows or has reasonable suspicion of child abuse, shall report
that knowledge or suspicion to a child protective agency immediately, or as soon as practically possible by
telephone, and shall prepare and send a written report thereof within 36 hours of receiving the information
concerning the incident.
Abuse is understood to include physical injury, sexual molestation, willfully causing or permitting a child to
suffer unjustifiable physical pain or mental suffering or willfully causing or permitting such child to be placed
in a situation that endangers the child’s person or health.
Any ambiguous reporting situation, including the decision to report past abuse of a person who is now an adult,
will initiate a phone consultation with the Child Abuse Registry.
As a part of the assessment of child abuse and the reporting requirement, the counselor will consult with the
Director. This consultation will be documented and the documentation will be retained by the Director in the
Confidential Administrative File.
If it is concluded that there is indeed a duty to report, the counselor will also notify the client at the time of
disclosure. Any exception to this policy will be discussed and documented with the Director.
Reporting Procedures are dictated by the Guilford County Department of Social Services and are as follows:
a.
A verbal report is made to Child Abuse & Neglect (336) 641-3795 as soon as
practically possible.
b.
The Report of Suspected Child Abuse form will be completed by Child
Protective Services.
The report shall include the name of the counselor making the report, the name of the child, his or her
whereabouts, the nature and extent of the injuries or molestation, if known, and any other information requested
by the child protective agency, including what led the counselor to suspect child abuse. The official reporting
form will be used, and a copy retained in the Confidential Administrative File.
Elder Abuse Reporting
North Carolina State Law mandates the reporting of physical abuse to an elder adult (65 years of age and over)
and dependent adults 18 to 64. It encourages persons to make reports of exploitation, neglect and abandonment
of any elderly or dependent adult 18 years of age and over. Mandated reporters include psychologists,
psychiatrists, licensed clinical social workers, and marriage, family, and child counselors.
When there is suspicion of elder abuse, the counselor will consult with the Director to determine whether a
report should be made. In any ambiguous case, the Elder Abuse Hotline will be called and consulted regarding
the reporting responsibility.
Reporting procedures are dictated by the Guilford County Department of Social Services and are as follows:
a.
A verbal report is made to Adult Abuse and Neglect (336) 641-3137 as soon as
practically possible.
b.
The Report of Suspected Dependent Adult/Elder Abuse form will be
completed by Adult Protective Service.
Responding to a Subpoena
In such cases, advice will be sought from the Vice Chancellor for Student Affairs and University Legal
Counsel. The goal of every such response will be to protect the client’s right to confidentiality.
Missing Persons Procedures
In the event that a student is discovered to be missing for a period exceeding 24 hours a report should be made
to one of the following university officials
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University Police Department
Dean of Students
Vice Chancellor for Student Affairs
Director of Housing and Residence Life
Following receipt of a missing student report, university officials will notify the A&T University Police
Department who will follow their own investigation procedures. If the student has designated an emergency
contact person with the university, the university will notify that individual within 24 hours of receiving a report
that the student is missing. North Carolina A&T students can confidentially designate an emergency contact
person by completing an Emergency Contact Registration form at http://www.ncat.edu/studentaffairs/housing/assets/downloads/forms/personal-data.pdf or residence hall students may fill one out when they
check in the residence hall. By law, the parent/guardian of students who are under 18 and not legally
emancipated will be notified in the event that the student has been reported as missing for 24 hours
Service Animals
North Carolina A&T State University Animal Policies
Service animals are animals trained to assist people with disabilities in the activities of normal living. The
Americans with Disabilities Act (ADA) definition of service animals is “…any dog individually trained to do
work or perform tasks for the benefit of an individual with a disability, including, but not limited to, guiding
individuals with impaired vision, alerting individuals who are hearing impaired to intruders or sounds,
providing minimal protection or rescue work, pulling a wheelchair or fetching dropped items.” If an animal
meets this criteria, it is considered a service animal regardless of whether it has been licensed or certified by a
state or local government or training program. Their service for the individual with a disability entitles them to
access of public places and common areas. Under the new ADA standards, miniature horses are recognized as
service animals. They must meet the same criteria as service dogs.
Individuals with disabilities who use a service animal on campus are not required to register with Disability
Support Services, but students who wish to have an assistance animal in student housing must make a formal
request for this accommodation through Disability Support Services.
Expectations for Service Animals
Because service animals are in close proximity to students and others, they must be quiet, obedient and wellgroomed. Specifically:
 The service animal must be up-to-date with check-ups and vaccinations.
 Vaccination and license tags must be displayed on the animal.
 All service animals must be well-behaved.
 Service animals must be under the control of the user at all times.
 Service animals must be clean, groomed, and free of ticks, or other pests.
 Animals are to relieve themselves in designated locations only.
 The animal user is responsible for promptly cleaning up after the animal.
 The animal user is responsible for any property damage caused by the animal.
 Service animals may be prohibited from areas that may be hazardous to the animal or its owner
(mechanical equipment rooms, laboratories, etc.)
 To assist the campus population in recognizing a service animal it is highly encouraged that service
animals be identified by a marked harness or cape but not required.
NCAT Housing
Assistance Animals
North Carolina A&T State University residence halls are covered under the Fair Housing Act and the U.S.
Department of Housing and Urban Development (HUD), and Section 504 of the Rehab Act in addition to the
Americans with Disabilities Act. Following is how the FHAct addresses Assistance Animals:
An assistance animal is not a pet. It is an animal that works, provides assistance, or performs tasks for the
benefit of a person with a disability, or provides emotional support that alleviates one or more identified
symptoms or effects of a person’s disability. Assistance animals perform many disability-related functions,
including but not limited to, guiding individuals who are blind or have low vision, alerting individuals who are
deaf or hard of hearing to sounds, providing protection or rescue assistance, pulling a wheelchair, fetching
items, alerting persons to impending seizures, or providing emotional support to persons with disabilities who
have a disability-related need for such support. For purposes of reasonable accommodation requests, neither the
FHAct nor Section 504 requires an assistance animal to be individually trained or certified. While dogs are the
most common type of assistance animal, other animals can also be assistance animals.
The Office of Disability Support Services will evaluate a request for a reasonable accommodation to possess an
assistance animal in a residence hall using the general principles applicable to all reasonable accommodation
requests.
1. Does the person seeking to use and live with the animal have a disability as defined by the ADA: a
physical or mental impairment that substantially limits one or more major life activity?
2. Does the person making the request have a disability-related need for an assistance animal?
o Does the animal work, provide assistance, perform tasks or services for the benefit of a person
with a disability, or provide emotional support that alleviates one or more of the identified
symptoms or effects of a person’s existing disability?
Where the answers to questions (1) and (2) are “yes,” the FHAct and Section 504 require the university to
modify or provide an exception to a “no pets” rule or policy to permit a student with a disability to live with and
use an assistance animal(s) in all areas of the premises where students are normally allowed to go, unless doing
so would impose an undue financial and administrative burden.
The request may also be denied if:
1. The specific assistance animal in question poses a direct threat to the health or safety of others that
cannot be reduced or eliminated by another reasonable accommodation, or
2. The specific assistance animal in question would cause substantial physical damage to the property of
others that cannot be reduced or eliminated by another reasonable accommodation. Breed, size, and
weight limitations may not be applied to an assistance animal. A determination that an assistance animal
poses a direct threat of harm to others or would cause substantial physical damage to the property of
others must be based on an individualized assessment that relies on objective evidence about the
specific animal's actual conduct — not on mere speculation or fear about the types of harm or damage
an animal may cause and not on evidence about harm or damage that other animals have caused.
Conditions and restrictions that housing providers apply to pets may not be applied to assistance
animals. For example, if Residential Life requires applicants or residents to pay a pet deposit, they may
not require applicants and residents to pay a deposit for an assistance animal.
Please Note:
Many of the same expectations that are in place for service animals apply to assistance animals.
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The assistance animal must be up-to-date with check-ups and vaccinations.
Assistance animals must be clean, groomed, and free of ticks, or other pests.
Animals are to relieve themselves in designated locations only (when applicable).
The animal user is responsible for promptly cleaning up after the animal.
The animal user is responsible for any property damage caused by the animal.
The animal must not be disruptive to others in the residence hall.
The owner is responsible for the animal at all times.
Please refer to Residential Life policies for more specific information.
Pets
Students are not permitted to have pets in residence halls except for fish in aquariums and those students
needing the assistance of a service animal. Aquarium size is limited to a 10 gallon tank per room.
RATIONALE: The residence hall environments are not designed for the proper care of pets. The presence of
pets affects the health of other residents, has the potential for property damage and inconvenience to other
residents.
11.
TESTING SERVICES
Counseling Services provides individual tests in personality, achievement, learning disabilities, aptitude and
career interest; conducts university testing in cooperation with school deans, department heads and faculty;
provides national admissions tests, and provides application and information for students pursuing graduate and
professional schools.
Counseling Services is an official testing center for national testing programs. Some testing programs included
are:
 College Level Examination (CLEP)
 National League of Nursing (NLN)
In addition to national testing programs, Counseling Services conducts testing programs that may be required or
desired by the University and individual departments. Current programs include:

Veteran & Disability Support- Learning Disabilities and ADHD Assessments.
When administering and proctoring testing programs, counselors:
 are responsible for the preparation of facilities and test administration for the room assigned.
 are thoroughly familiar with all test administration procedures and adhere to those procedures.
 are present at all times in each testing room.
 account for both used and unused test materials during and after testing. Testing materials are housed in a
secure area.
 follow testing administration procedures.
 start test in a timely manner.
 complete all forms, files, and reports and return them to the center supervisor.
 answer examinees questions; check identification, direct examinees to specific seats; distribute and collect
test materials, walk around the room quietly and frequently to guard against misconduct and ensure that
examinees are following directions.
12.
CONSULTATION AND TRAINING SERVICES
Consultation
Counseling Services provides and secures relevant information and resources through the use of local, state and
regional professional consultants. The Director and Counseling staff serves as consultants to the University and
the local community.
13.
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14.
STAFF DEVELOPMENT
Counseling staff are encouraged to maintain and improve their counseling skills to enhance their
effectiveness in providing services to students.
At least monthly, a special in-service program is arranged on a topic of relevance to current development
needs.
Counseling staff are encouraged to attend professional seminars, workshops and conferences relevant to
their work functions. Release time is approved by the Director.
Counseling Services endorses a philosophy of employee development, and encourages support personnel to
become involved in appropriate development opportunities such as: training offered by human resources
and local conferences. Ongoing, twice yearly as needed, training/review of confidentiality and ethics are
conducted by Counseling Services clinical staff.
All staff are encouraged to attend the various seminars, discussions, presentations, etc. that are offered on
campus; work schedules may be adjusted to accommodate attendance.
RESEARCH
Special statistical reports, surveys, and studies are conducted by the Counseling Services Office to provide
analytical assessments of student characteristics and staff performance. A survey to assess drug use on the
University campus is IRB approved, and is administered every two years.
15.
QUALITY ASSURANCE
It is the policy of Counseling Services to attend to the quality of care provided to students.
 Supervision is a large component of Quality Assurance.
 Surveys of student satisfaction and counselor evaluations are conducted 2-4 times per year to assess and
determine need for changing patterns or techniques of service delivery (See Appendix). Participants are
recruited in one of two ways. As students present for services, administrative or clinical staff may request
participation after providing a brief explanation of the purpose, typical time to complete, and voluntary
nature of participation. Additionally, clinical staff may recruit participants by e-mail. A blind copied e-mail
including an explanation of the survey’s purpose, the typical time to complete, the voluntary nature of
participation, and a link to the survey may be sent to those who have agreed to be contacted via e-mail on
screening paperwork.
 Twice yearly a review of policies and procedures is accomplished at staff meetings to assure that
counselors are aware of and comply with policies.
 Policies are reviewed and, if necessary, revised during the summer months of each year.
16.
ANNUAL REPORT
At the end of the fiscal year, the Director incorporates descriptive data on the Counseling Services program into
an Annual Report. Data are compared with that of previous years to detect trends, program strengths and
weaknesses, and suggestions for future goals and activities. This report is submitted to the Vice Chancellor for
Student Affairs and is available to the public.
17.
INTERNSHIP / TRAINING PROGRAM
The Counseling Services Office serves as a training laboratory for graduate students, particularly those from the
Department of Human Development and Services, and others who desire to complete their internship and
practicum experiences within a professional counseling setting. Students from surrounding colleges and
universities also participate in this program.
Interested students should submit required documentation to Training Coordinator. Requirements for these
students will be determined by their program instructors and supervisors.
Intern/Practicum/Shadow Graduate Student Confidentiality Form (see Attachment)
Conflicting Relationship acknowledgement Form (see Attachment)
Overview
Counseling Services’ Practicum/Internship Training Program is geared toward assisting the counselor trainee in
developing a core of professional competencies or skills that would enable the trainee to function effectively as
an entry level counselor. Request for placement should be submitted to Office of Counseling Services by
November 1st for Spring semester and May 1st for the Fall semester.
Placement
To be considered for placement the following is required:
1.
2.
3.
4.
5.
6.
Copy of Departmental Application for Field Placement
Resume/Vitae
One page description of professional objectives you desire during field placement
Copy of Department’s “On-Site Supervisor’s Qualifications, Rights and Responsibilities”
Copy of Liability Insurance
Interview with Site Supervisor and Director
Goals and Objectives
The goals of the Practicum/Internship Program in Counseling are:
1.
2.
3.
4.
5.
6.
To expose the trainee to various counseling tools, techniques and strategies.
To expose the trainee to various assessment techniques and strategies.
To assist the trainee in his/her professional development.
To increase awareness of issues related to diversity and ethics.
To learn outreach approaches for prevention (alcohol/drugs, suicide, etc.) on a college campus.
To develop skills in group therapy through observation and possible co-leadership.
Specific training and performance objectives for the practicum/internship in counseling are as follows:
Counseling Skills
1.







2.
The trainee will counsel at least five (5) clients with personal/social, academic or career concerns
and be able to demonstrate use of the following skills:
the ability to listen effectively;
the ability to respond to verbal and nonverbal behavior;
the ability to communicate time limits, confidentiality, expectations for client behavior and
expectations for the counseling process;
the ability to develop mutually agreed upon expectations and goals for counseling;
the ability to keep/update adequate clinical notes and records
the ability to make appropriate referrals; and
the ability to effectively terminate the relationship
The trainee will conduct a follow-up of each client's progress and discuss the observed behavioral
changes with a professional counselor.
Site Supervisor’s observation, review of audiotape and Trainee documentation shall be used to
evaluate these skills.
Assessment Skills
1.
The trainee will administer and score at least five (5) career or personality assessments, profile and
interpret to client if possible, and provide a demonstration of such skills.
2.
The trainee will participate in at least one (1) standardized testing program and be able to administer
and/or assist others in the administration of standardized tests.
Outreach
1.
The trainee will provide at least one (1) presentation on topic assigned by site supervisor. This may
include stress, study skills, relationships etc. in classroom or personal growth program.
2.
The trainee will assist with at least one (1) Counseling Services outreach initiative.
Professional Development
1.
The trainee will attend at least one (1) counseling related professional meeting, seminar, workshop
or program and present information regarding the program's content.
2.
The trainee will attend at least two (2) Counseling Services in-service training conferences if
provided and all staff meetings unless officially excused.
3.
The trainee will study community and University services and resource guides relevant to student
needs and demonstrate an ability to make appropriate referrals.
4.
The trainee will become familiar with the University's Student Affairs (Student Personnel)
Organizational Structure
and be able to identify where each of the various areas, especially
Counseling Services, fall under the umbrella-like structure.
5.
The trainee will become familiar with the Office Computer System and be able to log intake data,
locate information from the Student Master File and run office software.
6.
The trainee will demonstrate or develop at least one (1) new way of promoting or increasing student
awareness of Counseling Services.
All Practicum/Intern Trainees will work closely under the supervision of the Site Supervisor,
Counseling staff and the Director of Counseling Services.
Trainees’ Rights and Responsibilities
Rights
The trainee has the right:










to a quality training experience
to know the criteria for evaluation in the Internship
to know the expectations/procedures of the Internship
to know procedures for handling emergencies
to receive supervision
to request and receive additional supervision
to receive feedback from site supervisor
to ask questions regarding the counseling process and the correct handling of cases
to confidentiality
to reasonable accommodations
Responsibilities
The trainee has the responsibility:












to become familiar with the requirements for the Practicum/internship
for attendance and punctuality at site and supervisory sessions.
to be prepared for supervisory sessions
to act professionally at all times.
for maintaining hours and logs and providing a copy for Site supervisor on a weekly basis.
to request additional supervision as needed
to inform the supervisor of client emergencies
to follow professional ethical standards
to obtain written consent from at least one(1) client for audiotape and/or observation by Site
Supervisor for trainee evaluation
to maintain the confidentiality of clients
to explain confidentiality and its limitations to client
Reasonable Accommodation
In accordance with ADA regulations, trainees will be given reasonable accommodation(s) according to
his/her disability. It is understood that trainees with disabilities will request accommodation(s) upon
acceptance of placement.
Trainee Affirmation of Confidentiality
Counseling services are confidential, in keeping with ethical standards of the American Counseling Association,
and/or the American Psychological Association, and applicable national and state laws. No information is
released to outside parties without the client's prior written consent. All persons using Counseling Services are
advised in writing of the specific legal limits of confidentiality. (See Appendix for Intern/Practicum/Shadow
Graduate Students’ Forms).
Section 17: APPENDICES
NORTH CAROLINA AGRICULTURAL AND TECHNICAL STATE UNIVERSITY
REQUEST FOR LEAVE
EMPLOYEE:__________________________
_
DATE: __________________
__
_
Leave is hereby being requested for the period specified below. This form is to be filed with departmental leave information and
made available for review by this office for audit purposes. Information on leaves taken should be submitted to the Department of
Human Resources on the PD-113 or PD-110.
VACATION LEAVE:
DATES _____________________
(FROM)
(THRU)
If less than a day indicate time:
SICK LEAVE:
BONUS LEAVE:
TIME _________________________
(FROM)
(THRU)
DATES ______________________________
If less than a day indicate time.
___
TOTAL HOURS: _____________________
TIME _____________________________________
(FROM)
(THRU)
DATES _________________________________
If less than a day indicate time.
TOTAL HOURS ____________________
TOTAL HOURS:_____________
TIME: ________________________________________
(FROM)
(THRU)
OTHER LEAVE: _______________________DATES: ___________________TOTAL HOURS:____
______________________________
Applicant’s Signature
_
__
___________________________ __________ _______
Supervisor’s Signature
Date
LEAVE MUST BE REQUESTED AND APPROVED BY SUPERVISOR IN ADVANCE; EXCEPTIONEMERGENCIES.
VACATION LEAVE



May be taken by permanent employees in units of not less than 15 minutes.
Accumulated on a monthly basis, leave in excess of 240 hours on December 31 will revert to sick leave on January 1 of each
calendar year.
May be used for personal leave, vacation, and absences as a result of adverse weather conditions.
SICK LEAVE




May be taken by permanent employees in units of not less than one hour.
No maximum accumulation, it is cumulative indefinitely.
May be used for illness or injury, medial appointment, and temporary disability connected with child bearing.
May be used for death in the immediate family. (Family is wife, husband, mother, father, sister, brother, daughter, son,
mother-in-law, father-in-law, daughter-in-law, son-in-law, grandmother, grandfather, granddaughter, grandson, stepmother,
stepfather).
BONUS LEAVE


Bonus leave should be taken only upon authorization of the agency supervisor/department head.
Full-time employees who work less than 12 months receive a pro rata amount of the 80 hours.




Permanent part-time employees (half-time or more) receive a pro rata amount of the 80 hours.
Bonus leave may be used for any purpose for which regular vacation leave is used.
Bonus leave should be charged in units of time consistent with regular vacation leave guidelines.
The employee should determine whether to charge approved leave to regular vacation leave or bonus leave.
REMINDER
LEAVE OR TIME TAKEN IN EXCESS OF ACCUMULATION WILL BE LEAVE-WITHOUT PAY AND DEDUCTED FROM
SALARY CHECKS. THIS MAY CAUSE DELAYS IN PAYROLL CHECKS OR CANCELLATION OF CHECKS.
CONTACT YOUR SUPERVISOR FOR QUESTIONS
Or
HUMAN RESOURCES 334-7862
North Carolina A&T State University-Counseling Services
Consent to Release/Exchange Information
This form cannot be used for the re-release of confidential information provided to Counseling Services by other individuals or
agencies. Such requests should be referred to the original individual or agency.
I _______________________________________________________ authorize NC A&T State University to:
Name
DOB
 Release to:
 Obtain from:
 Mutually exchange with people listed on the attached page:
Name
_________________________________________________________________________________
Address _________________________________________________________________________________
_________________________________________________________________________________
Phone
_________________________________________________________________________________
The following information pertaining to myself will be disclosed/exchanged:
o  Treatment summary
o  History/intake
o  Diagnosis
o  Psychological test results
o  Psychiatric evaluation/medication history
o  Dates of treatment attendance
o  Other (specify) Group consultation
I understand that the information will be used for the purpose of:
o  Evaluation/assessment and/or coordinating treatment efforts
o  Referral
o  Contact with Psychiatrist or Physician
o  Other (specify) Interpersonal communication
This consent will automatically expire one (1) year after the date of my signature as it appears below.
I understand I have the right to refuse to sign this form, and that I may revoke my consent at any time (except to the extent that the
information has already been released).
__________________________________________________
Signature of Client
Date
__________________________________________________
Signature of Witness
Date
03/07
North Carolina A&T State University
Rights and Responsibilities of Students Using Counseling Services
I.
Rights
As a client of Counseling Services, you have certain rights, among which are the rights to respect, prompt service, and confidentiality.
a.
Appointment:
We are committed to providing quality services to all enrolled students.
b.
Prompt Service:
Counseling Services will schedule an initial appointment with a counselor as soon as possible, usually the same day. Failure to
attend scheduled appointments, or repeated cancellations, will result in the closure of your case.
c.
Respect:
The counselors in Counseling Services are expected to treat all clients with respect regardless of race, ethnicity, age, gender,
sexual orientation, lifestyle, creed, or religion. Counselors may convey this respect by keeping appointments, by giving you
complete attention during sessions, by avoiding interruptions during sessions, and by providing effective counseling.
d.
Treatment Participation:
Counseling is a participatory activity. In order for it to be effective, you must actively participate in establishing and working on
treatment goals, completing assignments, and discussing difficult issues. If the counselor feels that you are not actively
participating in treatment, (s)he can discontinue sessions until you are more ready to focus on your treatment issues. Similarly, if
you feel that the time is not right for you to focus on your treatment issues, you can discontinue treatment or select another
counselor of your choice. If you choose to discontinue treatment prematurely, we ask that you inform your counselor of your
intentions.
e.
Confidentiality:
All counseling involves the sharing of sensitive, personal, and private information by clients with their counselors. Recognizing
this, several federal and state laws, as well as a code of professional ethics, protect the confidentiality of information shared in
counseling. In addition, no information about whether or not you are being seen at Counseling Services; or about your actual
counseling, will be released to an outside agency or person without written permission from you. There are, however, a few
carefully agreed upon exceptions to confidentiality which we believe you should know about before you begin counseling. These
exceptions are as follows:

Staff Consultations and Supervision:
The staff of Counseling Services operates as a team. Therefore, from time to time, your counselor may consult with
other staff members or receive supervision from another member. These consultations are for professional and training
purposes only and are aimed at providing the best possible care for all clients.

Abuse of Children:
If your counselor has reason to believe that a child under the age of 18 is being abused or neglected, (s)he is legally
obligated to report this situation to the appropriate state agency.

Abuse of Elderly Individuals or Other Vulnerable Adults:
If your counselor has reason to believe that a vulnerable adult (i.e., elderly or a person over 18 years old who lacks the
physical or mental capacity to provide for his/her daily needs) is being abused, (s)he is legally obligated to report this
situation to the appropriate state agency.

`
Imminent Harm to Self:
If your counselor has reason to believe that you are in danger of physically harming yourself, and if you are unwilling
or unable to follow treatment recommendations, (s)he may have to seek your involuntary admission to a hospital and/or
contact a family member or another person who may be able to help protect you.

Imminent Harm to Others:
If your counselor has reason to believe that you are actually threatening physical violence against another person, or if
you are an actual threat to the safety of another person, (s)he may be required to take some action to insure that the
other person is protected (e.g., contacting the police, notifying the other person, seeking involuntary hospitalization).

Court Order to release Information:
We are legally required to release client information to the courts if a judge court orders your record. If such a situation
arises, we will make every attempt to inform you of the court’s request and the nature of the request.
The confidentiality exceptions described in “e” are extremely rare. If, however, they should arise, it is our policy that whenever possible, we will
discuss with you any action contemplated as fully as possible. However, you should know that we are not legally obligated to inform you, or seek
your permission, especially if such a discussion would prevent us from securing your safety or the safety of others. If disclosure of confidential
information does become necessary, we will release only the minimal information necessary to protect you and/or another person.
f.
Your Record:
According to State of North Carolina regulations for professional counselors, client records must be maintained for a period of
ten (10) years. Consistent with these regulations, Counseling Services keep both our paper and electronic records within a locked
structure for the designated time period. The bulk of your record is stored electronically with access restricted to the appropriate
staff members. Both paper and electronic files are destroyed after ten years of inactivity. Your counseling records are not part of
your academic record.
II.
Responsibilities
Your active participation in the counseling process is necessary for progress to be made. Therefore, along with your rights as a client,
you have certain responsibilities that include:
a.
Promptness:
Keeping to appointment times will allow you to take full advantage of your counseling sessions. Arriving promptly for your
sessions will allow you to make the most of your time.
b.
Attendance:
Once you have been scheduled for an appointment, it is your responsibility to keep the appointment. If an emergency arises,
please cancel your appointment by calling the office staff at the Center, giving as much advance notice as possible. Again, failure
to attend sessions, or repeated cancellations, will result in the closure of your case.
PLEASE LET YOUR THERAPIST KNOW IF YOU HAVE ANY QUESTIONS ABOUT THE ABOVE INFORMATION
Signature: ___________________________
Date: ___________________________
Student Referral Form
COUNSELING SERVICES
DIVISION OF STUDENT AFFAIRS
MURPHY HALL, SUITE 109
1601 EAST M ARKET STREET
GREENSBORO , NC 27411
(336) 334-7727
(336) 334-7284
WWW.NCAT.EDU
PHONE
FAX
WEB
Student Name:
Banner I.D. #:
Major:
Class:
Date of Birth:
Age:
Race:
Sex:
Email Address:
Phone Number:
Presenting Problem:
Symptoms:
Disposition:
EXPLORE
DISCOVER
BECOME
_______________ ________________________________________________________________
Clinician’s Signature
Revised: 7/20/11
A LAND-GRANT UNIVERSITY AND A CONSTITUENT INSTITUTION OF THE UNIVERSITY OF NORTH CAROLINA
Date
Information on Group Counseling
Group Counseling at NC A&T State University
Group counseling offers unique therapeutic possibilities to address a variety of student concerns. The goal of this handout
is to answer some frequently asked questions about group counseling so that you may learn more about this frequently
recommended form of therapy.
What Is Group Counseling Really Like?
Groups are typically composed of 5-8 members who meet weekly for 1 ½ hours. The issues discussed in the group are
generated by the group members, with guidance and facilitation by trained group leader(s). Some of our groups are timelimited and topic-focused. Other groups are open-ended and not focused on a particular topic. Confidentiality among
group members is always required.
What Are The Advantages Of Group Counseling?
A group provides opportunities to learn with and from other people and to understand your own patterns of thoughts
and behaviors (as well as those of others). Other people can often see attitudes and behavior patterns that are limiting
and that may be difficult to see in yourself.
A group is an opportunity to receive genuine support, honest feedback, and useful alternatives from peers.
A group is an opportunity to experiment with and work toward new attitudes and new ways of coping with life's
stressors.
A group may also help individuals deal with relationship concerns and general difficulties in dealing with other
people.
For What Types Of Concerns Is Group Counseling Most Helpful?
Group counseling is especially helpful for the following types of student concerns:
"My relationships with others are unsatisfactory, very frustrating, and/or disappointing."
"People don't react to me the way I would like them to."
"I feel stuck in a particular pattern or role in my relationships with others."
"I feel lonely and unsupported. Others don't seem to understand me."
"I lack assertiveness. I either don't address differences and disagreements or my disagreements with others turn into
hostile conflict."
"I want to change my way of thinking and feeling about myself."
Group counseling is one of the most direct ways to provide the type of contact needed to work through these concerns.
One Last Thing To Note
Students often feel a bit nervous or uncomfortable with the idea of joining a group. It's important to remember that the
group leader is aware of this and will work with the group to make the environment supportive and safe. Remember that
pursuing or confronting the things that make us most anxious can sometimes be the most beneficial way to help us
change.
GROUP INTEREST FORM
North Carolina A&T State University’s Counseling Services has an extensive group therapy
program. Many students overlook groups, feeling that they will not be able to have their
needs met through this format. You are strongly encouraged to consider one of the many
groups offered at Counseling Services, and, more often than not, you can begin ongoing
counseling in a group with little wait. If the issues you are struggling with are interpersonal
(relational) at all, many times group therapy is the preferred mode of treatment and can
address your needs in ways individual therapy cannot.
Please check any group or groups you might be interested in joining. If you would like
Counseling Services to offer a group that is not listed, please offer your suggestions at the
bottom of this form.
RELATIONSHIP GROUPS
Interpersonal Issues Group
Dysfunctional Family
Lesbian Interpersonal Group
Couples Enhancement
Women's Relational Group
Dating
Managing Relationship Conflict
Gay Men's Concerns
M en's Issues Group
SUPPORT GROUPS
Dissertation Thesis
Women Of color
Men of Color
Inter-Racial Couples
First Generation College Students
International Students
Chronic Pain/Disabilities
Non-Traditional Students
Single Parenting
Bi-Sexual Support Group
New Directions (Drug & Alcohol
reduction)
Transgender Support Group
ISSUES
Sexual Abuse
Sexual Assault
Obsessive Compulsive Disorder
Adult Children of Alcoholics
Bereavement/Grief
Depression Management
Anxiety
Stress Management/Relaxation Training
Phobias (Shyness, Public Speaking, etc.)
Eating Disorders / Body Image Issues
Bipolar Disorder
Anger Management
Attention Deficit Disorder
Combating Perfectionism
GENERAL GROUPS/CLASSES/WORKSHOPS
Life-skills: Stress Management &
Self-Esteem
Multicultural Leadership
Eating Awareness Workshop
Visualizing Success
Personal Issues
Other Suggestions for Groups :
If you would like someone to contact you about a group, please leave us your name and e-mail address.
Name and e-mail address :
Many thanks on behalf of the Counseling Services.
North Carolina A&T State University-Counseling Services
Intake Form
SECTION I:
Name: _____________________________________________________ Today’s Date: __________________
What do you prefer to be called? ________________________________ Banner ID#: ___________________
Date of Birth: ______________
Age: ______ Sex: _____________ Email: ________________________

Okay to leave message □
Local Address: _____________________________________________________________________________
Permanent Address: ________________________________________________________________________
Local Phone: __________________ Cell Phone: ___________________ Other Phone: __________________

Okay to leave message □
Class: FR SO JR
 Okay to leave message □
 SR Grad
International

Marital Status:
Okay to leave message □
Major: _________________________________________
Ethnic Background: African American Hispanic
Sexual Orientation:  Heterosexual

Native American
Biracial
Caucasian Asian
Other_______________________
 Lesbian
 Gay  Bisexual  Questioning  Other
Separated
Divorced
Prefer not to Answer
Single Married
Renamed
Widowed
Partnered 
How did you hear about the Counseling Center?
 Orientation
 Brochure
 Previous Client
 Counseling Program
Current/Prior Military Service  Yes or  No
SECTION II:
 Friend/roommate  RA/GA
 Professor/Advisor
________________________
Pending Court/Legal Issues Yes  or  No
Have you received services from Counseling Services previously? ___Yes ___ No
If yes, when: ______
Are you in good physical health?_____ Yes_____ No
Are you currently taking any medication? _____Yes
_____ No
If yes, list medications: ______________________________________________________________________
Have you ever been in counseling/psychotherapy? _____ Yes
_____ No
If yes, when were you last treated and by whom? _________________________________________________
Briefly state why you came to the Counseling Center. _____________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
When did you first become aware of this
concern?__________________________________________________________________________________
________________________________________________________
Number of nights per week that you consume alcohol: _____
Number of drinks per night: _____
Number of nights per week that you use mood-altering substances: _____
Substance(s) of choice and amount used: _______________________________________________________
__________________________________________________________________________________________
Have you ever tried to stop, cut down, or control gambling?
Yes
No
Have you ever lied to family members, friends, or others about how
much you gamble or how much money you lost on gambling?
Yes
No
Have there ever been periods of 2 weeks or longer when you spent
Yes
No
a lot of time thinking about your gambling experience, or planning
out future gambling ventures or bets?
__________________________________________________________________________________________
Yes
No
Have you made attempts to kill yourself in the past?
Yes
No
Are you currently engaging in any self-injurious behavior?
Yes
No
Are you currently having any thoughts about killing yourself?

Have you engaged in self-injurious behavior in the past?

Yes
No
Do you hear things or see things that other people do not?

Yes
No
Father’s Age: _____ Occupation: ______________________
Mother’s Age: _____ Occupation: ______________________ Parent’s Marital Status: __________________
Number of sister: _____
Their ages: ___________________________
Number of Brothers: _____ Their ages: ___________________________
Partner’s Age: _____ Occupation: ________________________________
Number of Children: _____ Their ages: ___________________________
List any family members who have substance-abuse problems (e.g., brother-marijuana, step- father-alcohol):
_______________________________________________________________________________________
PLEASE CHECK ALL THAT APPLY TO YOU:
1. Dislike campus rules and regulations
3. Not adjusting well to a new situation
5. Having difficulty trusting other people
7. Feeling depressed or unhappy
9. Thinking about killing myself
11. Having fears, which seem unrealistic
13. Bothered by insomnia or sleep difficulties
15. Feeling tired, dizzy and/or weak
17. Wishing I could be different
19. Grades too low
21. Unsure about my future plans
23. Concerned about my marriage
25. Upset about a physical problem
2. Worry about my eating habits
4. Worry about my drinking, smoking, or drug use
6. Do not get along with my parents or my family
8. Cannot seem to control my thoughts or behavior
10. Nervous or anxious much of the time
12. Worry about past physical or sexual abuse
14. Very anxious in social situations
16. Sexual needs unsatisfied
18. Having trouble studying
20. Upset by recent death
22. Having money problems
24. Disappointed by relationships
26. Confused by my sexual role
27. Having headaches, indigestion, or other
28. Other
physical problems
PLEASE LIST THE NUMBERS OF YOUR 3 MAIN CONCERNS: 1._____ 2._____ 3._____
SECTION III:
Name of person to contact in emergency:
________________________________________________________
Relationship to you: __________________________________ Phone:
________________________________
Signature: __________________________________________ Date: _________________________________
Section 504
Section 504 of the Federal Rehabilitation Act of 1973
This Act affects the use of a mandatory withdrawal for students with mental disorders and prohibits dismissing
a student solely because of a mental disorder. However, a student may be recommended for voluntary
hospitalization or subject to involuntary hospitalization for psychiatric reasons if the Director of Counseling
Services concludes, on the basis of clear and convincing evidence, that:
(1) the student is mentally ill, as defined by the current American Psychiatric Association Diagnostic and
Statistical Manual or its equivalent, AND
(2) the student has acted in such a way in the relevant past as to show that the student
a. Is dangerous to self because:
i. the student would be unable, without care, supervision, and the continued assistance of
others not otherwise available, to exercise self-control, judgment, and discretion in the
conduct of the student’s daily responsibilities and social relations, or to satisfy the
student’s need for nourishment, personal or medical care, shelter, or self-protection and
safety; AND
ii.
there is a reasonable probability of the student suffering serious physical debilitation
within the near future unless adequate treatment is given. A showing of behavior that is
grossly irrational, of actions that the student is unable to control, of behavior that is
grossly inappropriate to the situation, or of other evidence of severely impaired insight
and judgment shall create a prima facie inference that the student is unable to care for
him/herself; OR
iii. the student has attempted suicide or threatened suicide and that there is a reasonable
probability of suicide unless adequate treatment is given.
Previous episodes of dangerousness to self, when applicable, may be considered when
determining reasonable probability of physical debilitation, suicide, or self-mutilation.
b.
Is dangerous to others because:
Within the relevant past, the student has inflicted or attempted to inflict or threatened to inflict serious
bodily harm or another, or has acted in such a way as to create risk of serious bodily harm to another,
or has engaged in extreme destruction of property; and that there is a reasonable probability that this
conduct will be repeated. Previous episodes of dangerousness to others, when applicable, may be
considered when determining probability of future dangerous conduct.
ADDICTIVE BEHAVIORS ASSESSMENT
Please answer yes or no to the following questions.
Section I
1.
Have you ever been arrested on a MIP (Minor In Possession) charge or been at a party broken up by police?
2.
Have you ever been suspended from school activities for using alcohol/drugs or skipping classes?
3.
Do you have a poor attitude about school and/or family life?
4.
Have you dropped activities that used to be important to you?
5.
Do your friends drink or smoke marijuana?
6.
Have you ever experienced a hangover or bad trip due to alcohol/drug use?
7.
Have you ever lied to others about your alcohol/drug activities?
8.
Have you made excuses about your drinking/using behavior (i.e.: I only do it at parties or when I’m stressed)?
9.
Have you made excuses about drinking/using behavior of your friends?
10. Have you experienced any unexplainable mood changes or emotional ups and downs that seem excessive to you?
Section II
11. Have you ever been arrested for shoplifting, vandalism, driving while impaired (DWI), or possession of alcohol/drugs?
12. Have you ever been suspended from school possession of alcohol/drugs or fighting?
13. Have any of the following occurred frequently: sleeping in class, declining grades, or skipping classes?
14. Have you changed friends from those who don’t use alcohol/drugs to those who do?
15. Have you experience significant weight loss or gain?
16. Do you have a more difficult time paying attention than you used to?
17. Do you feel less motivated than you used to?
18. Have you experienced memory lapses (times when you couldn’t remember going somewhere or doing something?
19. Have you experience feelings of depression, hopelessness, or worthlessness?
20. Do you strongly defend your right to drink or use drugs?
Section III
21. Have you ever been arrested for robbery, drug dealing, assault and battery, vandalism or prostitution?
22. Have you been suspended from school more than once or expelled?
23. Have you been fired from a job?
24. Have you gotten physically violent with your parents or other family members?
25. Have you gotten violent with your friends?
26. Have you started avoiding your friends to the point where they have begun expressing concern?
27. Do you blame other people for your problems?
28. Do you feel angry a lot of the time?
29. Have you ever made suicide plans, left notes or actually attempted suicide?
30. Have you experienced feelings of paranoia?
Section IV
31. Have you often found yourself thinking about gambling [e.g., reliving past gambling experiences, planning the next time you
will play or thinking of ways to get money]?
32. Have you needed to gamble with more and more money to get the amount of excitement you are looking for?
33. Have you become restless or irritable when trying to cut down or stop gambling?
34. Have you gambled to escape from problems or when you are feeling depressed, anxious or bad about yourself?
35. After losing money gambling, have you returned another day in order to get even?
36. Have you lied to your family or others to hide the extent of your gambling?
37. Have you made repeated unsuccessful attempts to control, cut back or stop gambling?
38. Have you been forced to go beyond what is strictly legal in order to finance gambling or to pay gambling debts?
39. Have you risked or lost a significant relationship, job, educational or career opportunity because of gambling?
40. Have you sought help from others to provide the money to relieve a desperate financial situation cause by gambling?
Reviewed 05/2012
kdeane
COUNSEL.EDU
FROM:
Dr. Vivian Barnette
Licensed Psychologist & Executive Director
DATE:
February 11, 2011
RE:
Credit for Participation: “Relationships ~ Love Letter”
______________________________________________________________________
This is to certify that_____________________________ did participate in the
“Relationships ~ Love Letter” Workshop on Monday, February 14, 2011, Stallings
Ballroom A-side 2:00 p.m. – 4:50 p.m.
Sessions Attended:
____ 2:00 – 2:50 p.m.
Music in Relationships
Presenters: Chandra Caple, M.Ed., NCC, LPC
Victoria Dalton, MS, NCC, LPC
Kelly Deane, M.A., Ed., NCC, LPC
N. C. A & T. S. U.
____
EXPLORE
DISCOVER
BECOME
3:00 - 3:50 p.m.
How not to date/marry a Jerk/Jerkette
Presenter: Dr. Sebrina Cooke-Davis
Parent Educator
Family Life Council of Greensboro
____
4:00 – 4:50 p.m.
Safe Sex Talks
Presenter: Janet Lattimore
Medical Health Program Consultant
N. C. A. & T. S. U.
A LAND-GRANT UNIVERSITY AND A CONSTITUENT INSTITUTION OF THE UNIVERSITY OF NORTH CAROLINA
Client Satisfaction Survey
Text of Survey Distributed Through Qualtrics
Counseling Services routinely requests feedback from those who have visited our center. The survey used to
collect feedback takes approximately 5-7 minutes to complete and is anonymous in nature.
Gender (select one)
Male
Female
Transgender
Race/Ethnicity (select one)
African-American/Black
Anglo-American/White
Asian-American/Pacific Islander
Hispanic/Latino
Native American
More than one ethnicity
Prefer not to say
Additional demographics (check all that apply)
Student-Athlete
Veteran
International student
Transfer student
Sexual orientation (select one)
Heterosexual/Straight
Lesbian
Gay
Bisexual
Questioning
Queer
Other
Classification
Freshman
Sophomore
Junior
Senior
Graduate
Non-degree seeking
Counselor's Name
Vivian Barnette
Calena Creft
Victoria Dalton
LaKisha Ellison
Anthony Greenidge
Roy Hamilton
Daniel Paredes
Sammy Ngetich
What is your major?
[write in]
Number of sessions
1 (15-minute screening only)
2-4
5-7
8 or more
Type of service your received
Individual counseling
Educational testing (LD/ADHD)
Career assessment
Couples counseling
Group counseling
Please rate your AGREEMENT with the following
[Strongly Agree – Agree – Disagree – Strongly Disagree]
My counselor was respectful of who I am as an individual (culture, religion, ethnicity, sexual orientation, etc.)
My counselor helped me feel like I could share my thoughts, concerns, or questions
My counselor was able to understand my problems and concerns
Counseling Services has helped me to improve my academic performance
Counseling Services has helped me remain enrolled in school
Please rate your AGREEMENT with the following statements
Strongly Agree – Agree – Disagree – Strongly Disagree]
Counseling Services has helped me cope better with the concerns that brought me in
My counselor was knowledgeable of how to help me
My counselor was effective with the ways she/he worked with me
Please rate your SATISFACTION with our general office and other staff
[Very Satisfied – Satisfied – Neither satisfied nor dissatisfied - Dissatisfied – Very Dissatisfied]
Counseling center location convenient/accessible
Privacy in the reception area
Comfort in the reception area
Politeness of staff in the reception area
Helpfulness of staff in the reception area
Relevance of written materials in the waiting area
Please rate your AGREEMENT with the following
Strongly Agree – Agree – Disagree – Strongly Disagree]
Overall, I am satisfied with the counseling I have received
I would seek services again at Counseling Services, if needed
I would refer a friend to Counseling Services
If you could change one thing about Counseling Services, what would it be?
[write in]
Please list any groups or topics that you would like Counseling Services to cover/offer
[write in]
Additional comments for us
[write in]
Comfort in the reception area
Privacy in the reception area
Politeness of staff in the reception area
Helpfulness of staff in the reception area
Ease of appointment scheduling
Relevance of written materials in the waiting area
Please rate your AGREEMENT with the following
Overall, I am satisfied with the counseling services I have received.
Counseling Services has helped me to improve my academic performance.
Counseling Services has helped me remain enrolled in school
Counseling Services has helped me cope better with the concerns that
brought me in
Counseling Services has positively impacted my relationships.
I would seek services again at Counseling Services if needed.
I would refer a friend to Counseling Services.
If you could change one thing about Counseling Services what would it be?
Please list any groups or topics you would like Counseling Services to
cover/offer
Additional comments for us
Once you have completed the survey, click on the SUBMIT button
below. Let our staff know when you are done.
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NORTH CAROLINA
AGRICULTURAL AND TECHNICAL STATE UNIVERSITY
COUNSELING SERVICES
DIVISION OF STUDENT AFFAIRS
MURPHY HALL, SUITE 109
1601 EAST MARKET STREET
GREENSBORO , NC 27411
(336) 334-7727
FAX (336) 334-7284
WWW.NCAT.EDU
Practicum/Internship Form
Name: __________________________
PHONE
WEB
Phone number: ____________________
Program of Study (major): _____________________
School: ___________________________
University Faculty Supervisor/Coordinator: _____________________
I am interested in:
Practicum 
Hours Requirements: (on-site) ________
Internship 
(client contact) ________
Supervision Requirements:
Supervision hours/week ______
Specific supervisor credentials required _________
Number of graduate courses that have been completed in the following areas:
Ethics _____
Assessment _____
Group _____
Diversity _____
Diagnosis (DSM) _____
Brief explanation of past clinical experience (50-words or less):
EXPLORE
DISCOVER
BECOME
A LAND-GRANT UNIVERSITY AND A CONSTITUENT INSTITUTION OF THE UNIVERSITY OF NORTH CAROLINA
Counseling Services Training Program for
Master’s and Doctoral Students in Mental Health Professions
Overview
The training program at Counseling Services is focused on helping participating students develop
competencies and skills necessary for the next step in their professional development. Students
from various mental health professions are invited to apply for acceptance into the training
program. Requests for placement at Counseling Services should be submitted to the Practicum
Coordinator or Internship Coordinator no later than 1 November for Spring semester
participation and 1 May for participating in the subsequent Fall semester.
Placement
To be considered for placement the following is required:
1. Copy of Counseling Services Form
2. Copy of Department’s “On-Site Supervisor’s Qualifications, Rights and Responsibilities”
3. Copy of Liability Insurance
Following review of submitted materials, an interview with Counseling Services training staff
may be required. Completion of a Counseling Services confidentiality agreement is required
prior to acceptance.
Training Program Goals and Objectives
The goals of the Training Program to:
1. expose the trainee to various counseling tools, techniques and strategies.
2. expose the trainee to various assessment techniques and strategies.
3. assist the trainee in his or her professional identity development.
4. increase awareness of issues related to diversity and ethics.
5. learn outreach approaches for prevention (alcohol/drugs, suicide, etc.) on a college
campus.
6. develop skills in group therapy through observation and possible co-leadership.
Specific training and performance objectives for the trainee’s field experience will be
established as supervision goals at the outset of the trainee’s time at Counseling Services.
Supervision, Peer Consultation, & Professional Development
Participants in the training program will be required to participate regularly in supervision or
peer consultation, and professional development meetings. The frequency and duration of
meetings will vary depending on trainee educational requirements, Counseling Services staff
availability, and needs identified during the trainee’s development. As a general rule of
thumb, trainees are provided one hour of individual supervision per week and participate in
one 30-minute “journal club” professional development meeting per week.
Recording of Sessions
Practicum/Internship participants who have received permission from their Counseling
Services supervisor may audiotape sessions, with the appropriate consent from the client(s).
Audio files should be stored in the secure file cabinet used to store client files. A computer
will be provided for trainees to routinely back-up their recorded sessions on an external
media device that also will be kept in a secure file cabinet. Sessions being submitted to the
university supervisor should be transferred onto a disc or thumbdrive containing only that
session to limit the exposure of other clients in the event the disc or thumbdrive is lost.
Video recording is not permitted at Counseling Services.
All copies of recorded sessions will be destroyed at the end of each academic semester.
Affirmation of Confidentiality
Counseling services are confidential, in keeping with ethical standards of the American
Counseling Association, and/or the American Psychological Association. No information is
released to outside parties without the client's prior written consent. All persons using
Counseling Services are advised in writing of the specific legal limits of confidentiality. (See
Appendix for Intern/Practicum/Shadow Graduate Students’ Forms
NORTH CAROLINA
AGRICULTURAL AND TECHNICAL STATE UNIVERSITY
COUNSELING SERVICES
DIVISION OF STUDENT AFFAIRS
MURPHY HALL, SUITE 109
1601 EAST MARKET STREET
GREENSBORO , NC 27411
(336) 334-7727
(336) 334-7284
WWW.NCAT.EDU
PHONE
FAX
WEB
Internship/Practicum/Shadow Graduate Student
Confidentiality Form
All counseling involves the sharing of sensitive, personal, and private information
by clients with their counselors. Recognizing this, several federal and state laws, as
well as professional ethical codes, protect the confidentiality of information shared
in counseling.
___________________________________________________________________
As a trainee at North Carolina A&T State University Counseling Services, I
understand and agree:

I will adhere to all the policies and procedures of North Carolina A&T State
University and Counseling Services

I will not search or read the contents of client files, nor will I discuss the
students with whom I have contact, other than with Counseling Services
clinical staff.

I may not use any names or identifying information when documenting or
discussing my training experience for class.

I will follow the supervision and direction of the counselor to whom I have
been assigned.

I understand that failure to adhere to the aforementioned terms will result in
dismissal from the field experience at Counseling Services.
A copy will be provided to me and one will be retained in my supervision file.
Print Name: __________________________
Signature: ___________________________
Date: _______________________________
Phone: ______________________________
EXPLORE
DISCOVER
BECOME
E-mail: _____________________________
Counseling Services supervisor signature:
A LAND-G RANT UNIVERSITY AND A CONSTITUENT INSTITUTION OF THE UNIVERSITY OF NORTH CAROLINA
NORTH CAROLINA
AGRICULTURAL AND TECHNICAL STATE UNIVERSITY
COUNSELING SERVICES
DIVISION OF STUDENT AFFAIRS
MURPHY HALL, SUITE 109
1601 EAST MARKET STREET
GREENSBORO , NC 27411
(336) 334-7727
(336) 334-7284
WWW.NCAT.EDU
PHONE
FAX
WEB
Dear Prospective Trainee:
We are excited about your interest in a training experience in Counseling Services.
The training program in Counseling Services is geared towards assisting students
develop a core of professional competencies that will enable them to function
effectively as entry level counselors. We are all licensed professionals and utilize a
team approach to assist you in accomplishing your educational goals.
Opportunities for Masters Level students include Shadow Experience, Practicum and
Internship. Those seeking a Shadow Experience should contact me, the Training
Coordinator, to schedule an interview. Students seeking a Practicum or Internship
Experience should apply by providing the requested information found in the
Overview. Requests for placement should be submitted to Training Coordinator by
November 1st for spring semester and May 1st for fall semester.
On behalf of the Director and Staff, thank you for your interest in Counseling Services.
We look forward to the opportunity to work with you.
Sincerely,
Victoria l. Dalton, M.S., NCC, LPC
Victoria L. Dalton, M.S., NCC, LPC
Training Coordinator
EXPLORE
DISCOVER
BECOME
A LAND-GRANT UNIVERSITY AND A CONSTITUENT INSTITUTION OF THE UNIVERSITY OF NORTH CAROLINA
NORTH CAROLINA
AGRICULTURAL AND TECHNICAL STATE UNIVERSITY
CONFIDENTIALITY AGREEMENT
COUNSELING SERVICES
DIVISION OF STUDENT AFFAIRS
MURPHY HALL, SUITE 109
1601 EAST MARKET STREET
GREENSBORO , NC 27411
(336) 334-7727
(336) 334-7284
WWW.NCAT.EDU
PHONE
FAX
WEB
Counseling Services, a unit within the Division of Student Affairs at North Carolina A&T
State University (NCAT), provides personal counseling to NCAT students. The responsibility
of Counseling Services and its representatives (i.e., employees, consultants) is to maintain the
confidentiality of all information regarding a client’s contact with Counseling Services. This is
a legal mandate and critical to our image as a counseling center. Counseling Services does not
release information to any person or agency including university personnel, other students, or
associates within or outside the university without the consent of the client except in certain cases,
as defined by law.
Therefore, as a Counseling Services representative I agree: (If a clinical staff member or
administrative assistant, initial items 1-4; if a consultant to Counseling Services (e.g., IT
personnel, translator) or student worker, initial items 1-5):
_____ 1. To not disclose to any person the name of any client seen at Counseling Services
without the client’s consent as required by law.
_____ 2. To not confirm or deny any person’s knowledge that another person is a client at
Counseling Services.
_____ 3. To refrain from reading/reviewing client files that is not directly related to my work
responsibilities, both during and after my employment at Counseling Services.
_____ 4. To refrain from copying the electronic database of client information or removing any
client data from the premises of Counseling Services without explicit permission from
a Counseling Services administrator.
_____ 5. To refrain from seeking any information concerning any clients seen at Counseling
Services during/after my employment.
Any representative who breaches client confidentiality will risk immediate sanction, up to and
including termination and/or legal action. Additionally, if the employee is a university student, they
may face sanctions through the Dean of Students.
I have read and agree to abide by the above policy.
Signature: ____________________________________________
Date: _________________
Witness: ______________________________________________ Date: __________________
EXPLORE
DISCOVER
BECOME
A LAND-GRANT UNIVERSITY AND A CONSTITUENT INSTITUTION OF THE UNIVERSITY OF NORTH CAROLINA
NORTH CAROLINA A&T STATE UNIVERSITY – COUNSELING SERVICES
GRADUATE STUDENT SHADOWING EXPERIENCE
ATTENDANCE ROSTER
STUDENT NAME: ________________________________________
Please
Print Legibly
date
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Activity/program
time
Signature of
counseling
staff
COUNSELING SERVICES
Minor Informed Consent
STATEMENT OF INFORMED CONSENT FOR PARENTS AND GUARDIANS
A North Carolina A & T State University college student for whom you are legally responsible, and who
is a minor, has requested counseling services at the North Carolina A & T State University Counseling
Services. Individuals who are under 18 years of age cannot legally give informed consent for treatment or
referral beyond the intake process. However, please be advised that in an emergency situation, we may
be compelled to offer treatment or referral prior to obtaining your informed consent. You are asked to
carefully read the information contained on this sheet and to sign it in the appropriate space on the back.
If you have any questions about this information or about the services offered by Counseling Services,
please do not hesitate to contact us at the number noted below.
This document is designed to provide some basic information about the counseling process. Please
review carefully and sign it in the appropriate space if you agree to allow a minor for whom you are
legally responsible to participate in counseling.
ELIGIBILITY FOR SERVICES
Currently enrolled North Carolina A & T State University students are eligible for Intake services at the
University Counseling Services facility. Following the intake process, it will be determined whether the
University Counseling Services facility is the appropriate place for the student to receive ongoing
counseling. Please be assured that if it is determined that Counseling Services is not the appropriate place
for the student to receive treatment, a referral to an appropriate mental health treatment provider will be
made. All services at Counseling Services are offered free of charge.
TYPES OF COUNSELING SERVICES OFFERED
The University Counseling Center offers individual, couples and group counseling. Typically, clients are
seen for one session per week; the duration of each session is approximately 50 minutes. Counseling takes
place in the context of a helping relationship in which the counselor and the client work together to
resolve a problem, change behavior or foster personal growth and awareness.
CONFIDENTIALITY
In keeping with professional standards and legal requirements, the client’s records, and the information
the client discloses to a counselor, are confidential. The client’s records at Counseling Services consist of
the client’s contact card and other intake documents, session notes and a termination report. Records are
kept for the client’s benefit and, therefore, the client may have access to his or her record, unless the
information it contains is determined to be detrimental to the client. In that case, the client may request a
summary of the information contained therein. If the client is under 18 years of age, his or her parent or
guardian holds the privilege of confidentiality.
At times, it may be necessary to consult with other professional staff within Counseling Services about
clients in order to provide the best possible service. However, we will not share information about clients
outside of the Center without the client’s written authorization, which allows us to communicate with
specific others. Be assured that a client’s visit to the Counseling Center are not noted in their official
school record. If the client is under 18 years of age, his or her parent or guardian must provide written
authorization to share information with others outside of Counseling Services. You should be aware that
there are exceptions to the privilege of confidentiality. A counselor must disclose information when it
is necessary to protect the client or others from harm, in cases where child or elder abuse is suspected,
upon court order, or as required by law.
ROLE OF THE COUNSELOR
Although the counselor will not and should not tell the client what to do, she or he will assist with
generating solutions to problems and concerns. Also, the counselor will be a caring and attentive listener,
which many clients find helpful in and of itself. In addition, the counselor can be an advocate for the
client within the university, contacting deans or professors, whenever necessary or appropriate.
ROLE OF THE CLIENT
The client’s active participation in the counseling process is necessary for progress. Therefore, clients are
strongly urged to attend all scheduled sessions. If a client must miss a session, he or she should notify us
as early as possible by calling 336-334-7727. Should the client fail to keep two (2) consecutive
appointments without notifying us to cancel the session, he or she will no longer be considered an active
client at the Center. However, students are welcome to schedule an appointment at another time.
CRISIS RESPONSE PLAN
If a client experiences a crisis (including thoughts about hurting oneself or someone else) that takes place
during regular business hours, please contact the client’s counselor by phone at Counseling Services (336334-7727). You should let the person answering the phone know that this is an emergency. If the
counselor is not immediately available, ask to speak to another counselor. Clients should not e-mail their
counselors for any situation that requires an immediate or urgent response. At times when the Center is
closed and you believe that your child is experiencing a crisis, please go directly to the emergency room
at your local hospital or call 911 for assistance. If the student is an on-campus resident, please notify a
member of the Residential Life staff to inform them that your child needs immediate assistance or call
336-334-7675 for the University Police and Public Safety Department.
RISKS INVOLVED
Although the benefits of engaging in the counseling process can be enormous, there may be some risks, as
well. For example, sometimes people feel worse before they feel better. This is because, at times, painful
feelings emerge that must be worked through and resolved. Also, the feelings and issues that arise in the
counseling process may be intense enough to distract one from other things that demand one’s
attention, important activities such as school work. If feelings do become too painful and distracting,
clients and/or parents should let their counselor know.
EXPECTATIONS ABOUT COUNSELING
The counseling process often takes time. Therefore, it is probably not realistic to expect that one’s
problems will be solved after one or two sessions. Because counseling is a process, it is wise to give it a
few weeks before one decides whether or not it is working. However, if after a few weeks, one continues
to feel that counseling is not helping, or that one has not made a good connection with the counselor,
there are steps that can be taken. The client can speak openly and candidly with the counselor about these
concerns. The counselor can alter what he or she is doing or refer the client to another counselor. If
speaking directly to the counselor is too uncomfortable, the client can ask the secretary of Counseling
Services to set up an appointment with another counselor. However, whenever possible, it is best to
speak with the counselor first.
GIVING INFORMED CONSENT TO COUNSELING
Your signature below indicates that you have read the information contained in this document and that
you agree to allow a minor for whom you are legally responsible to participate in the counseling process.
Student please note that your signature below indicates that you have read and understand all the
information contained in this document.
Please Print (Parent / Guardian)
Date
Signature (Parent / Guardian)
Date
_______________________________________
Please Print (Student)
_______________________________________
Date
Signature (Student)
_______________________________________
Date
Letter to parent re: minor student
February 8, 2016
Dr. XXX XXX
XXXXXXX Valley Drive
XXXXXX, NC 27301
Dear XXX. XXX:
XXXXX has contacted the Counseling Services at North Carolina A & T State University for
assistance. Because she is a minor, it is necessary for us to have your written consent in order to
provide our services to her. This permission would extend until her 18th birthday. Attached is an
Authorization to Release and/or Obtain Confidential Information form that she has signed for
this purpose.
Approved Abbreviations
#YO
#YY
AEB
APPT
CBT
CLT
D
DO
DOS
DX
ED
GF
GM
HI /SI
HPW
HS
HX
I
I/DD
INDV
JND
LGBT
M
MGM
MH
MI
MSC
NOS
Years older
Years younger
As evidenced by
Appointment
Cognitive Behavioral therapy
Client
Direction
Disorder
Dean of Students
Diagnosis
Emergency department
Grandfather
Grandmother
Homicidal ideation/suicidal ideation
Hours per week
High school
History
Impression
Intellectual and developmental disability
Individual
Just noticeable difference
Maternal
Maternal grandmother
Mental health
Motivational interviewing
Multicultural Student Center
Not otherwise specified
Office of veteran and disability support
OVDSS
services
PM
Per month
P
Paternal
PGM
Paternal grandmother
PW
Per week
PX
Problem
ROI
Release of information
SX
Symptoms
T
Theme
TCF
Telephone call from...
TCT
Telephone call to...
TMF
TMT
TX
VM
WNL
UPD
Telephone message from...
Telephone message to...
Treatment
Voice mail
Within normal limits
University Police Department
Drug/Alcohol Groups
Drug/Alcohol Groups are offered periodically. The Drug/Alcohol Program focuses on four
components:






Orienting members to the group (see Appendix)
Assessing level of usage and potential for addiction (see Appendix).
Providing education on the physical and mental effects of the substance.
Recognizing and preventing potential addiction.
Creating awareness of available rehabilitative services.
Making Referrals to outside providers for treatment as needed (see Appendix)
Professional standards of confidentiality are observed.
Personal Growth Programs
Counseling Services sponsors four student seminars per year on developmental topics. This
programming requires that counselors leave their office to venture into the academic and student
community to provide relevant activities, programs and services to meet the needs of the student.
Outreach programming consists of personal growth seminars on topics such as: Skills for Student
Success, Drug and Alcohol Issues, Relationships, Skills for Career Success, Communication,
Diversity, Domestic Violence, Sexual Assault Prevention, and Time/Stress Management.
Workshop topics are relative to national college trends.
In addition to student seminars, counselors conduct special workshops or presentations for
campus and community groups.
Section 17: APPENDICES
Appendix actual
FORM PD-109
RESOURCES
REVISED 10/02
DIVISION OF HUMAN
NORTH CAROLINA AGRICULTURAL AND TECHNICAL STATE UNIVERSITY
REQUEST FOR LEAVE
EMPLOYEE:__________________________
_
_
DATE: __________________
__
Leave is hereby being requested for the period specified below. This form is to be filed with departmental leave
information and made available for review by this office for audit purposes. Information on leaves taken should be
submitted to the Department of Human Resources on the PD-113 or PD-110.
VACATION LEAVE: DATES _____________________
____________________
(FROM)
(THRU)
If less than a day indicate time:
TOTAL HOURS
TIME _________________________
(FROM)
(THRU)
SICK LEAVE:
DATES ______________________________
_____________________
If less than a day indicate time.
_
(THRU)
DATES _________________________________
If less than a day indicate time.
TOTAL HOURS:
TIME _____________________________________
(FROM)
BONUS LEAVE:
___
TOTAL HOURS:_____________
TIME: ________________________________________
(FROM)
(THRU)
OTHER LEAVE: _______________________DATES: ___________________TOTAL HOURS:____
__
______________________________
Applicant’s Signature
___________________________ __________ _______
Supervisor’s Signature
Date
LEAVE MUST BE REQUESTED AND APPROVED BY SUPERVISOR IN ADVANCE;
EXCEPTION- EMERGENCIES.
VACATION LEAVE

May be taken by permanent employees in units of not less than 15 minutes.


Accumulated on a monthly basis, leave in excess of 240 hours on December 31 will revert to sick leave on
January 1 of each calendar year.
May be used for personal leave, vacation, and absences as a result of adverse weather conditions.
SICK LEAVE




May be taken by permanent employees in units of not less than one hour.
No maximum accumulation, it is cumulative indefinitely.
May be used for illness or injury, medial appointment, and temporary disability connected with child
bearing.
May be used for death in the immediate family. (Family is wife, husband, mother, father, sister, brother,
daughter, son, mother-in-law, father-in-law, daughter-in-law, son-in-law, grandmother, grandfather,
granddaughter, grandson, stepmother, stepfather).
BONUS LEAVE






Bonus leave should be taken only upon authorization of the agency supervisor/department head.
Full-time employees who work less than 12 months receive a pro rata amount of the 80 hours.
Permanent part-time employees (half-time or more) receive a pro rata amount of the 80 hours.
Bonus leave may be used for any purpose for which regular vacation leave is used.
Bonus leave should be charged in units of time consistent with regular vacation leave guidelines.
The employee should determine whether to charge approved leave to regular vacation leave or bonus leave.
REMINDER
LEAVE OR TIME TAKEN IN EXCESS OF ACCUMULATION WILL BE LEAVE-WITHOUT PAY AND
DEDUCTED FROM SALARY CHECKS. THIS MAY CAUSE DELAYS IN PAYROLL CHECKS OR
CANCELLATION OF CHECKS.
CONTACT YOUR SUPERVISOR FOR QUESTIONS
Or
HUMAN RESOURCES 334-7862
What Is Group Counseling Really Like?
Groups are typically composed of 5-8 members who meet weekly for 1-1 ½ hours. The issues discussed
in the group are generated by the group members, with guidance and facilitation by a trained group
leader(s). Some of our groups are time-limited and topic-focused. Other groups are open-ended and not
focused on a particular topic. Confidentiality among group members is always required.
What Are The Advantages Of Group Counseling?
A group provides opportunities to learn with and from other people and to understand your own
patterns of thoughts and behaviors (as well as those of others).
A group is an opportunity to receive genuine support, honest feedback, and useful alternatives from
peers.
A group is an opportunity to experiment with and work toward new attitudes and new ways of coping
with life's stressors.
A group may also help individuals deal with relationship concerns and general difficulties in dealing
with other people.
For What Types Of Concerns Is Group Counseling Most Helpful?
Group counseling is especially helpful for the following types of student concerns:
"My relationships with others are unsatisfactory, very frustrating, and/or disappointing."
"People don't react to me the way I would like them to."
"I feel stuck in a particular pattern or role in my relationships with others."
"I feel lonely and unsupported. Others don't seem to understand me."
"I lack assertiveness. I either don't address differences and disagreements or my disagreements with
others turn into hostile conflict."
"I want to change my thoughts and feelings about myself."
Group counseling is one of the most direct ways to provide the type of contact needed to work through
these concerns.
One Last Thing To Note
Students often feel a bit nervous or uncomfortable with the idea of joining a group. It's important to
remember that the group leader is aware of this and will work with the group to make the environment
supportive and safe. Remember that pursuing or confronting the things that make us most anxious can
sometimes be the most beneficial way to help us change.
GROUP INTEREST FORM
North Carolina A&T State University’s Counseling Services has an extensive group therapy
program. Many students overlook groups, feeling that they will not be able to have their
needs met through this format. You are strongly encouraged to consider one of the many
groups offered at Counseling Services, and, more often than not, you can begin ongoing
counseling in a group with little wait. If the issues you are struggling with are interpersonal
(relational) at all, many times group therapy is the preferred mode of treatment and can
address your needs in ways individual therapy cannot.
Please check any group or groups you might be interested in joining. If you would like
Counseling Services to offer a group that is not listed, please offer your suggestions at the
bottom of this form.
RELATIONSHIP GROUPS
Interpersonal Issues Group
Dysfunctional Family
Lesbian Interpersonal Group
Couples Enhancement
Women's Relational Group
Dating
Managing Relationship Conflict
Gay Men's Concerns
Men's Issues Group
SUPPORT GROUPS
Dissertation Thesis
Women Of color
Men of Color
Inter-Racial Couples
First Generation College Students
International Students
Chronic Pain/Disabilities
Non-Traditional Students
Single Parenting
Bi-Sexual Support Group
New Directions (Drug & Alcohol
reduction)
Transgender Support Group
ISSUES
Sexual Abuse
Sexual Assault
Obsessive Compulsive Disorder
Adult Children of Alcoholics
Bereavement/Grief
Depression Management
Anxiety
Stress Management/Relaxation Training
Phobias (Shyness, Public Speaking, etc.)
Eating Disorders / Body Image Issues
Bipolar Disorder
Anger Management
Attention Deficit Disorder
Combating Perfectionism
GENERAL GROUPS/CLASSES/WORKSHOPS
Life-skills: Stress Management &
Self-Esteem
Multicultural Leadership
Eating Awareness Workshop
Visualizing Success
Personal Issues
Other Suggestions for Groups :
If you would like someone to contact you about a group, please leave us your name and e-mail address.
Name and e-mail address :
Many thanks on behalf of the Counseling Services.
Outreach Request Form
* Required
Title and description of the event (i.e., panel discussion, presentation, etc.) *
Date & Time of Event*
Month
Hr
Day
:
Min
2014
AM
Location*
Duration of the program (i.e., 50 mins)*
Sponsoring organization or department*
Approximate number of attendees expected*
Number of counselors requested
Contact person name*
Contact person e-mail address*
Contact person telephone number*
Other Comments
[,,"-73248055910
0
-7324805591038
NORTH CAROLINA A&T STATE UNIVERSITY – COUNSELING
SERVICES
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Emergency Manual Counseling Services 2009-2010.pdf