Center of Counseling

Consent From

Counseling Center of National Chiao Tung University

Consent Form of Individual Counseling

 

1. Confidentiality

Your information in counseling is confidential and will not be disclosed to anyone without written consent.

*Confidentiality is reserved in the following two circumstances:

t Imminent risk of self-harm, suicide, or abuse of others.

t Information disclosure is required by law, e.g. child welfare law.

 

2.Free Service

Counseling service is free to the staff and students of Chiao Tung University..3

 

3.Time

Each counseling session is for 50 minutes per session, once a week. However, this may be adjusted if necessary.

 

4.Cancellation

If you need to cancel an appointment, please contact us 24 hours before-hand, by calling us (ext.51303) or coming to counseling center personally.

 

5.Consent of audio/video recording

For the purpose of supervision, counselor may take audio or video recording during counseling session. However, you have the right to refuse it. If you need a copy of the tape, please discuss with your counselor. In this case, you are responsible for its confidentiality.

 

6.Adherence

While your counseling is ongoing, you may ask second opinions from other counselors. However, in principle, you will stay with one counselor from the beginning to the end.

 

7.Termination

You have the right to terminate counseling at any time. However, because termination is an important part of the counseling process, please discuss with your counselor if you have this need.

 

8.Consent of referral

In order to help you efficiently, counselor may refer you to other counselors or a psychiatrist with your consent. Your counseling record will be transferred at the same time.

I understand and agree the above information.

 

Signature:                          Date:

* If you have any questions or concerns about this, please discuss with your counselor.