ASPIRE Clinic Informed Consent for Service and Notice of Receipt
The ASPIRE Clinic is a training, research, and service facility housed within the College of Family and Consumer Sciences at
the University of Georgia. Persons seeking services often have many questions about what to expect from the clinic. As a
result, we have developed an initial consultation process that will assist us in better understanding your needs and expectations.
Your service provider will gather information in a number of different areas in order to get an accurate and holistic picture of
your situation. At the end of the consultation, you may decide about continuing with further appointments. If you make the
decision to continue, your initial service provider will be assigned to work with you. Your signature(s) below indicate that you
are making an informed decision about entering services. If you have any questions about anything on this form, please discuss
it with your service provider or contact the Clinic Coordinator. By signing below, you understand:
1) Your service provider is a graduate or undergraduate student working toward a bachelor’s, master’s, or doctoral degree in
the School of Family and Consumer Sciences, within the departments of Human Development & Family Science
(Marriage and Family Therapy), Textile, Merchandising and Interiors (Home Environment Consulting), Foods and
Nutrition (Nutrition), and Housing and Consumer Economics (Financial Planning). Your service provider may also be a
law student of the UGA School of Law (Legal). Clinical faculty who are Approved Supervisors by the American
Association for Marriage and Family Therapy closely supervise therapists. Clinical faculty, with professional credentials
through the Association of Financial Counseling and Planning Education, the Certified Financial Planner Board of
Standards, or the International Foundation for Retirement Education, closely supervise financial providers. Clinic faculty
who closely supervise legal service providers are licensed attorneys in the state of Georgia. To allow collaboration
between service providers and supervisors, sessions are routinely recorded and/or observed by supervisors and clinic
service providers. Only the ASPIRE supervisor(s), service providers, and clinical staff view sessions or recordings.
2) The discussions that take place in sessions are confidential. Information about you or your family cannot be shared
without your written permission.
3) By law, there are specific limits to confidentiality. By the Rules and Regulations of the State of Georgia, your
confidentiality does not apply when there is clear and imminent danger to you or others, in which case your service
provider may take reasonable steps to protect those at risk including, but not limited to, warning any identified victims and
informing the responsible authorities. Should any of these situations occur your service provider would inform you of their
responsibilities and actions.
4) ASPIRE Clinic originates and maintains records that may describe any or all of the following: your history, noted issues or
symptoms, clinical diagnoses, current personal circumstances, financial information, test results, treatment, and plans for
future services. These records are used for the following purposes: (a) planning services, (b) communication among
ASPIRE Clinic staff who contribute to your services, (c) a means to verify that services billed were actually provided, and
(d) a tool to assess the quality of services provided.
5) ASPIRE Clinic’s policies and procedures regarding training, supervision, emergencies, payment for service, missed or
cancelled sessions, and email contact.
6) You have the right to request restrictions as to how your case information may be used or disclosed to carry out services,
payment, or clinic operations and understand that the ASPIRE Clinic is not required to agree to the restrictions requested.
7) You can revoke your consent at any time by writing your request to the attention of the Clinic Coordinator. If you revoke
your consent, the ASPIRE Clinic may refuse to serve you further, except to the extent that the ASPIRE Clinic is required
by law to treat you. If you wish to discuss any privacy issues or concerns, please contact the ASPIRE Clinic Coordinator.
Beyond the aforementioned confidentiality policies, I wish to have the following restrictions to the use or disclosure of my
health information: ____________________________________________________________________________________
Fee for Services
You understand that for-cost services at ASPIRE are on a sliding scale based on annual income and dependents/household size.
You have discussed the fees for service with the ASPIRE Clinic and your fee for each session, with the exception of the initial
consultation, will be $_____.
Cancellation policy: Scheduled sessions that are not cancelled 24 hours in advance or not attended will be charged a
cancellation fee of $10.00, added to the fee for the next appointment.
By signing, you fully understand and accept the terms of this consent, the negotiated fee for services, and acknowledgement of
receipt of notice.
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Client (1) Signature
Client (2) Signature
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Client (3) Signature
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Client (4) Signature
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Service Provider (Witness) Signature