SGO SP. Counseling Informed Consent Form

Welcome to LSPR Student Guidance Office Counseling Center. Please take a few minutes to read through this informed consent form to understand more about counseling and get to learn more about the solutions that can address your concerns to get you back on track.

COUNSELING. Counseling is a process carried on in a one-on-one social engagement between SGO Staff and students, acting to help a client seeking to learn more about himself or herself, exploring difficulties, and to understand the society that surrounds himself or herself in reaching defined positive goals for a better chance to become a productive member of society.

CONFIDENTIALITY. We highly respect the privacy and confidentiality of each of our student. We likewise believe that for counseling to be effective and successful, we must make our student feel secure about the information that they disclose with us. We keep our student's records in a secure manner and we do not allow it to be accessed or to be shared with anyone else unless with the written consent of our client who owns the information, both clinical information and personal. If records receive no update within a period of 7 years, we purge the records for privacy protection.

However, we would like to let you know that privacy has its limitations in law and we would like to inform you of the circumstances where we may share information to a 3rd party without your consent:

Acts of sexual abuse or misconduct
Criminal acts
Acts of abuse towards others such as neglect towards children, disabled, or the elderly
Acts that the therapist believe may cause harm to the client himself or to others
Compelling legal orders by the court, but nonetheless we will inform the client immediately prior to compliance with the order.

RELATIONSHIP. The relationship required for effective counseling is strictly professional. This is for the best interest of the parties. The counselor cannot have any other relationship with the client than a professional one.

CONSENT

I understand that this consent is purely voluntary. I have had the opportunity to discuss any concerns with regard to the services and treatment and by which all questions were answered accordingly and to my satisfaction.

I understand that I can withdraw anytime from the therapy by informing my therapist. By signing below, I expressly give my consent to the treatment and therapy sessions with the therapist.

Poster (mading, toilet, ect)Social Media (instagram)BannerWord of mouth ( ex: friend), lecture)

I hereby declare that I am of legal age and I freely give my consent to this foregoing treatment.

LSPR Sudirman Park, JakartaLSPR Transpark Juanda, BekasiLSPR e-Learning/PJJ

Name*

NIM*

Class*

Phone Number 1*

Phone Number 2*

Parents Phone Number*

Email*

example@example.com

Walk InParent ReportReferral

DoneIn ProsesOther

Ms. Prischa NovaMrs. Ira TBMs. Hanny Mustika DheaMs. Adelia Maudina Amanda

Things To Do*

Next Section*

Signature

Parent/Guardian Name

Signature of Parent/Guardian

Rows	5	4	3	2	1
My counsellor listened to me effectively.
My counsellor understood things from my point of view.
My counselllor focused on what was important to me.
My counsellor accepted what I said without judging me.
My counsellor showed warnth toward me.
My counsellor fostered a safe and trusting environment.
My counsellor gave me alternative ways to solve problem.
My counsellor helped me to gained a better understanding of myself.

Rows	5	4	3	2	1
After counseling I understand the main point essential of my problem.
After counseling I found ways to solve my problem.
After counseling I feel better and positive.

Rows	Very Satisfied	Satisfied	No Strong Feeling	Dissatisfied	Very Dissatisfied
My overall level satisfaction with the service provided by my counsellor is:

STUDENT GUIDANCE OFFICE