Counseling Services Intake Form

I, the client, agree to meet with Counseling staff at the appointment times and places we agree upon for the time frame of 50 minutes each. 

The therapy hour is yours. It starts at a specific time and ends at a specific time. Staying longer in a session or coming late for your appointment may interfere with other appointments. So, we ask that you be prompt and responsible in coming to your appointments. In return, Counseling staff make the same commitment to you. If you are unable to attend the session during the scheduled time, please make a best effort to notify the counselor as soon as possible in order to reschedule. Staff will return the same courtesy to you if one of us needs to cancel or reschedule your important appointment.

Psychotherapy varies depending on the therapist, the client, and the client's particular situations and goals. There are many different methods staff may use to assist you with your particular situation, goals, and objectives. For the best outcome, each client must choose to invest energy in the process and work actively on things we talk about both during and between our sessions.

Psychotherapy can have benefits and risks. The risks may include experiencing uncomfortable feelings like sadness. guilt, anger, anxiety or frustrations when discussing certain aspects of your life. Psychotherapy has been shown to have benefits that can include better relationships, solutions to specific problems, increased life satisfaction, improved physical health, and significant reductions in feelings of distress. However, there are no guarantees as to what each client will experience.

Drury Counseling staff believes and understand the basic ideas, goals, and methods of therapy. Do you have any questions or concerns?

Counseling Services at Drury University maintains policies, procedures, and ongoing programs to ensure that the following rights of each client arc protected by all personnel: 

• Every client has the right to respect and dignity as a human being.
• Every client has the right to self-direction and self-development.
• Every client has the right of choice and responsibility for decisions reached.
• Every client has the right to know the risks and benefits of counseling procedures.
• Every client has the right to access their counseling file by submitting their request in writing.
• Every client has the right to be informed about any tape recording or videotaping of counseling sessions.
• Every client has the right to refuse service.
• Every client has the right to terminate services at any time without just cause.
• Every client has the right to refuse to participate in experimental research.
• Every client has the right lo file a complaint with the Director of Counseling and/or Dean of Students.
• Every client has the right to be fully informed of all services provided by this counseling service and the cost of any referral sources.
• Every client has the right to voluntarily participate in the counseling process.

The client's of Drury University's Counseling Services will maintain the following responsibilities: 

• Every client must respect the rights of other clients.
• Every client must cancel appointments in a timely manner.

Counseling staff will respect the privacy of clients and will, within certain limits, hold in confidence the fact that the client is involved in counseling and all information obtained in the counseling relationship. With the exceptions described below, counselors will reveal information about a client only with the informed consent of the client.

At times, the counselor needs to discuss with other professionally trained counselors the work they do with clients. The counselors will not routinely inform clients of these consultation discussions, but will do so if sharing ideas gleaned from consultation would be valuable lo the counseling process. You will be asked to sign a release of information form authorizing your counselor to share information about your counseling to these professionals. If you have reservations about authorizing this release of information, you may discuss your concerns with your counselor prior to beginning counseling.

There are certain situations in which information about clients may be released without their permission. These situations are as follows:

• When the counselor determines the disclosure is necessary to protect against a clear and imminent risk of serious harm to the client or to another person. In such cases, the information will be disclosed only to appropriate professional workers, necessary university and public authorities. a potential victim of aggression or the client's family.
• When the counselor determines that abuse of children or vulnerable dependent adults is occurring. In these instances, a report must be made to the Missouri Department of Human Services.
• When the counselor is presented with and cannot successfully contest a court order for the release of such information.
• When the client makes a suicide attempt or requires hospitalization for psychological problems, severe substance abuse or life-threatening eating disorder. The counselor must notify the client's parents or spouse, the Dean of Students and if the client lives in a residence hall, appropriate members of the housing staff . Only relevant, limited and necessary information will be shared with these persons. who are always notified whenever a serious medical emergency of any kind arises with a student.

In the preceding situations, the counselor will, whenever possible, first discuss the disclosure of information with the client. The counselor will provide reasons why the disclosure is appropriate and necessary and will attempt to secure the client's permission to release information. However, should the client fail to give permission, the counselor must proceed to release information even without the client's consent. In some emergency situations there may not be an opportunity to discuss disclosure of information with the client before the counselor actually makes the disclosure. 

The above information is only to be released to, and/or from, the following party: Burrell Behavioral Health staff working at Drury University.

I understand that the purpose of the use or disclosure of information is to provide continuity of care. I further understand that this information will not be forwarded to anyone else by the recipient without my written consent. This authorization shall remain in effect until one year from the date of this agreement at which time it shall expire and no further release of information shall be made under its terms. If this line is left blank, this authorization will automatically expire one year from the date of my signature as it appears below. I am aware that I may revoke this consent to release information at any time, except where actions have already been taken on the basis of this release.