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Consent Form

Counseling Center of National Chiao Tung University

Consent Form of Individual Counseling

※※※※※※The English translation is for reference only※※※※※※
For the most up-to-date information, please refer to the Chinese version

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.



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

  • The counseling sessions for the faculties are 6 times at the most.
  • For each student, the duration of the appointments for the counseling sessions could be made for one year at the most. If there are extra needs, it is still possible for the adjustment to be made.



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.

  • If there are two absents without notification, your counseling session will be canceled.(If there are farther needs, you have to neapply for the future appointments and wait for the arrangement to be made.)


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.



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.



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.