Counseling & Psychological Services
Center for Student Health, Counseling & Wellness
Client Consent Form
Counseling & Psychological Services provides counseling, psychiatric, consultation, and prevention services
to enhance students’ potential for leaning and success and to promote the emotional health and well-being of
the campus community.
The Counseling Process:
College Counseling is an information sharing process designed to help you address your concerns, to obtain
relief from your symptoms, to come to a fuller understanding of yourself, and to learn effective personal and
interpersonal coping strategies. It involves a partnership between you and a trained therapist who has the
knowledge, expertise and experience to help you accomplish your individual goals.
Scope of Care:
Counseling & Psychological Services (CPS) utilizes a short-term, time-limited therapy model to assist students
who are experiencing concerns and needs that are interfering with their ability to be successful in school and/or
with their individual personal growth, functioning and adjustment. The overall objective is not to uncover and
address every issue with which a student may have faced in his/her life or to provide continual maintenance for
chronic psychiatric disorders. Rather, our objective is to facilitate adaptation, adjustment and resilient
functioning in order to enable the student to continue enrollment in college and to pursue academic, career and
personal success with minimal disruption or delay.
Individualized Treatment Goals:
The therapeutic approach utilized by CPS is flexible, individualized and driven by the specific treatment goals
negotiated between the student and clinician as well as by ongoing monitoring of measures to determine the
effectiveness of treatment and the levels of recovery or improvement. Consequently, the duration of treatment
is variable, but clinicians work to facilitate adjustment, successful functioning, problem resolution, and/or
symptom relief as soon as possible.
Confidentiality:
Confidentiality is an essential part of the therapeutic relationship. Information shared by clients generally will
not be disclosed or released to individuals outside the Center for Student Health, Counseling, and Wellness
without the client’s written or verbal permission. While restricted, disclosure of some degree of information is
nevertheless permitted, and at times mandated by law and/or ethical standards, without the student’s consent in
specific circumstances. It is important to understand that in all those instances where disclosure is necessary or
required, the sharing of information will be limited to the minimum amount of information relayed to the
minimum number and roles of individuals that is necessary to achieve the purpose of the disclosure (i.e., only
need-to-know information to need-to-know persons).
Counseling & Psychological Services records are separate from all other RIT records. If the disclosure of
information to a party outside CPS is desired by a student, students may authorize this by completing a release
of information form.
Background Checks:
Some employers and government agencies as part of background checks for employment or co-op placements
request or even require applicants to sign consent forms to release information about their counseling histories.
It is the policy of CPS that all requests for information accompanied by an authorization for release signed by
the student from institutions such as the military, FBI, Peace Corps, graduate schools, employers, etc., will be
handled by the Director (or designee) and discussed with you, if you are accessible, as well as the investigative
agent prior to the release of any information.
Finally, you may discover during the process of therapy the importance or benefit of social support networks
including family members and may wish to authorize your therapist to speak with someone regarding your
progress, issues or needs. It is at your discretion to provide written authorization about what specific
information and to whom you grant permission to your therapist to disclose.
You must be on time for your appointments. Please notify us at (585) 475-2261 if you will be late.
Because of the high volume of students we serve, we ask that whenever possible that cancellations be made
at least 24-hours in advance of a scheduled appointment.
There is no fee for counseling services. Psychiatry services are available to students through the
Student Health fee. If you are referred to an off-campus health, mental health, or substance abuse
professional you will be responsible for any associated charges.
I have read and discussed the above information with my therapist. I understand the risks and benefits of
counseling, the nature and limits of confidentiality, and what is expected of me as a client of Counseling &
Psychological Services.
______________________________
Signature of Client
Revised: August 2015
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Date
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Signature of Therapist