Part I

Professional Disclosure and Informed Consent Statement

Candice L. Zakariya, Lamar University Student

Department of Counseling & Special Populations

It is a pleasure to have the opportunity to work with students as I am training to obtain

my certification to be a school counselor in the state of Texas. The purpose of this document is to

provide students and parents/guardians with information about my professional training,

therapeutic practices, and counseling philosophy. You will also gain understanding of the

counseling relationship, the rights of clients, as well as confidentiality and its limits in

counseling. This consent will be explained to your student verbally and I will explain the benefits

and risks of counseling and the limits of confidentiality. The form at the end of this disclosure

statement must be signed by both the student and a parent or legal guardian and returned to the

counselor before the students participate in counseling services. I look forward to working with

your student.

Education and Qualifications

I am currently a student enrolled at Lamar University to obtain a Masters of Education in

School Counseling, which is accredited by the American Counseling Associations Council for

the Accreditation of Counseling and Related Educational Programs (CACREP), the nationally

recognized accrediting agency for counseling graduate programs. As I am gaining experience as

a practicum student, it is my desire to grow in my professional competence and skills with k-12

students. As an educator, students have described me as caring, approachable, and helpful and it

is my hope to utilize these personal strengths to provide counseling services to all students on my

campus.
Professional Affiliations

I am a professional student member of the American Counseling Association (ACA) and

the American School Counseling Association (ASCA).

Treatment Approach

My counseling approach with students is based upon Person-Centered and Solution

Focused Brief Therapy. In counseling sessions, it is important for me to provide an environment

that is based on unconditional positive regard, empathy, and genuineness. I believe that students,

have all the resources needed to successfully navigate current challenges they may face

academically, personally, socially and for future career development needs. Students and I will

work together to help them explore how to use those resources to solve these challenges. I

believe this can be accomplished through incorporating role-playing, hands-on activities,

technology, and other creative techniques, whether in the classroom, small groups, or individual

counseling sessions. It is important for me to focus on how students can reach their goals and

continue utilizing techniques for continued success.

Students always have the right to consent to treatment; similarly, students have the right

to withdraw that consent at any time. If for any reason, a student feels that I am not benefiting

him or her in our counseling relationship, I will take it upon myself to help find another

counselor for him or her to continue counseling services.

Professional Relationship

As a professional school counselor, it is important for me to maintain a professional

relationship with students I work with here at our school. During this school year, as we work

together, it is important for all students to know that counseling cannot be confused with a

friendship or social relationship. All of our interactions are limited to meeting for counseling
sessions, group meetings, and classroom guidance lessons. There are some occasions where as a

school counselor, I attend school functions and sports events, but these to support our school

community and not individual students. As a school counselor, I do not accept gifts from

students or relate to students outside of school. Although students may have opportunities to

learn about me through our counseling relationship, students are experiencing me in my role as a

school counselor.

Confidentiality

Anything discussed during counseling sessions will remain confidential according to

federal and state laws, as well as ethical professional guidelines. This means that I will not share

anything that is discussed with me except under the following situations:

If someone is hurting the student.

If the student plans to harm him or herself.

If the student plans to harm someone else.

If an adult or an elder is being abused and/or neglected.

If a judge tells me I have to appear in the court of law.

If the student is participating in a group counseling session, I will encourage all group members

to keep all that is discussed as confidential, but I cannot guarantee that it will be upheld by group

members.

Notice of Privacy Practices and Clients Rights

I have been given the HIPPA of Privacy Practice and Clients Rights. I understand that

the information given below is my preferred contact information for my privacy rights in being

contacted.

Consent for Treatment of Minors (if applicable)

 In the case that in as a parent, I/we consent that my child __________________ may be

treated as a client by the above referenced counselor.

Other Important Information

As a student, I, __________________ , understand that my participation in group

counseling should involve my willingness to participate with openness and honestly with the

other members of the group as I seek to reach the goals I set for myself and our group goals. I

understand that I may experience both positive and negative emotions during the weeks we have

group sessions. I am volunteering to enter this counseling relationship and promise to work hard

with both the school counselor and other students in the group.

I hereby consent to and agree to receive counseling services and acknowledge that I have

received a copy of the Professional Disclosure Statement for Rebecca Frels. I recognize that she

is a counseling intern and that at any time I would like to contact her supervisor, I should do so.

Signatures

Name of Student: ___________________________________

Preferred way to be contacted: ___________________________________

Contact Information: ___________________________________

___________________________________ Student Signature

___________________________________ Parent/Guardian Signature

________________________Date

Please include the name and phone number of any person you wish for me to contact in case of

an emergency or crisis.

Name of Emergency Contact: ___________________________________

Contact Information: ___________________________________

Part II

As a professional school counselor, I understand that before I meet with students for

counseling, they will need to be informed of what the counseling relationship will entail. I expect

that both parents and students will have questions about what counseling is, what it will look

like, and what rights the student and parent(s) have when it comes to understanding

confidentiality. I also expect parents to not always agree with their students right to

confidentiality. Therefore, it would be important for me to be sure that both the student and

parent have a correct understanding of the limits of confidentiality, as well as the counseling

relationship.

Although I would seek to have every student and their parent(s) to have received and

signed a Professional Disclosure and Informed Consent Statement, it is also my ethical

responsibility to discuss the contents of the document with each and every student before any

counseling sessions or group meetings begin. Students would come to understand that the limits

of confidentiality mean that anything they share with me will not be shared with anyone,

including their parents or teachers, unless I believe that they have or are at risk of harming

themselves or other people. This would also be explained to parents, so that they do not expect

that they would be able to know about any information that their child and I have discussed in

counseling. I would also explain that their student has the right to share anything with them if

they would like. I am always a proponent of students and parents having an open and honest

relationship. However, it is not my responsibility to facilitate that relationship.

 Both the student and parent(s) must understand that confidentiality within a group setting

is highly encouraged and even set as a group rule for the group; however, confidentiality cannot

be guaranteed as other members are responsible for their own actions. As a counselor, I

encourage student group members to share openly and honestly, but if there is anything that they

want to discuss with me personally, they may do so. Confidentiality between myself and the

student, as well as the limits of confidentiality are maintained as I seek to uphold the school

counseling profession is an ethical manner.

I understand the importance of confidentiality, as I had a friend experience a lack of

confidentiality when she was receiving counseling at her church. My friend was a widow in her

thirties and struggled every single day with grieving the loss of her husband. She sought out

counseling at her church, but after a while, she realized that her pastor had shared some

confidential information with his wife, who in turn shared information with other church leaders

and even her children. It all come out one day when she and the choir director had a

disagreement and all of her business was aired in front of everyone at choir rehearsal. My friend

immediately left the church with more hurt than when she began counselor. She now has to deal

with the loss of her husband and the betrayal she experienced with members of the church she

loved.

If this were to happen in my group. I would have confronted the issue during group,

while explaining how not upholding confidentiality hurts not only the individual, but the entire

group. Other group members will no longer be able to truly be open and honest during group

meetings knowing that other confidentiality was betrayed. I would also follow up with the

individual in one to one counseling and work through the issues that may have arisen as a result

of their confidentiality being broken.