Please read this form in its entirety. This information contained on this sheet is offered to ensure that you are given all the neccessary information to make an informed decision in regard to counseling, sports psychology, and/or consultation services. Do not hesitate to mention if you have any questions, need clarification, or if anything is unacceptable in you. 

Session Meetings 

The first meeting will begin with an interview of one hour or less, during which time a variety of questions will be asked in order to determine the best course of action. When Psychology Services (PS) staff provide their recommendations for the next step (e.g.,performance consultation, psychotherapy, referral, testing, observations, etc.), you may decline any or all of the recommendations, with the understanding that doing so may result in a less than ideal outcome. Continued session meetings will last approximately 30-50 minutes.

Treatment and/or Consultation

It is MSU’s Medical philosophy that sport psychology counseling and consultation is a joint effort. Your active participation is a key factor for successful outcome. We will jointly create a plan based on your needs and goals. Benefits of treatment and/or consultation may include reduction of your symptoms, improved quality of life, improved athletic performance, and emotional well-being. This process requires effort on your part, may require you to face difficult issues and/or effect changes, and may involve emotional risk or discomfort. There is no guaranteed outcome. You always have the right to request changes in, or to refuse, consultation and treatment at
any time.

Keeping Appointments

Because of the high demand for services, please contact MSU’s Medical staff 24 hours in advance if you need to reschedule or cancel your appointment. Failure to do so may affect your ability to access psychological services.

Confidentiality

Information that you reveal to MSU’s Medical staff will be confidential. This information will not be released outside of the Michigan State Sports Medicine Team without your consent. However, given Michigan NASW Ethical Standards and Guidelines, some or all of your information may be revealed to appropriate parties in certain circumstances. Examples of these confidentiality exceptions
include: response to a valid subpoena or court order for medical records; risk of danger to yourself or others; responsible belief that a child or vulnerable adult is at risk for abuse or neglect; legal mandate such as the USA Patriot Act of 2001. If you are utilizing insurance benefits, certain information may be required to be disclosed to your insurer. You have the right to obtain information in your records and/or treatment summary. A request for such records must be in writing. Systematically the following classes of persons are permitted to communicate with MSU’s Medical staff regarding your protected mental health information for mandated case consultation and medical decisions:(please initial as acknowledgment of this permission)  Sports Medicine Team including physicians, counselors, athletic trainers,and nutritionists. 

Emergencies

If you or anyone you know are experiencing an immediate life-threatening experience, please utilize the following services in the event providers are unavailable.

·         911- all emergencies

·         988-Suicide and Crisis Lifeline

·         Text either “Home”, “START”, or “HELLO” to 741741-Crisis Text Line

·         (800) 799-7233-National Domestic Violence Hotline

·         (800) 656-4673-National Sexual Assault Hotline

Acknowledgement/ Consent I have reviewed this Professional Counseling Informed Consent Agreement. I likewise understand my Client's Rights set in this form.My signature below indicates my consent for treatment and/or consultation