Heads UP Consent Form
  • Informed Consent - Heads UP Program

  • Chou Hallegra , our current counselor completed a post-graduate program in Rehabilitation Counseling and an Advanced Diploma in Biblical Counseling. She is a Certified Cognitive Behavioral Group Therapist, a Certified AutPLay Therapy Provider, a Certified Mindfulness Trainer and Coach, and a licensed trauma-informed care trainer. She completed additional training in compassion fatigue, Parent Child Interaction Therapy (PCIT) for traumatized children, as well as grief and anxiety treatment  Below are some information that’s important for you to know as you receive counseling services though her.

     

    Rights and Risks:

    ●        You may ask questions about any aspect of the counseling process.

    ●        If you have been referred by a court or state agency, you have the right to divulge only what you want to be included in a report.

    ●        Counseling is most effective when you are open and can speak honestly about your emotions and experiences.

    ●        Counseling may include talking about emotionally provoking subjects and scenarios. 

     

    Confidentiality:

    ●        Information shared by you in session will be kept confidential.

    ●        Information will not be released without your written consent, except for professional consultation if needed and unless required by law.

    ●        I am required by law to disclose information pertaining to suspected child abuse, the inability to care for one’s basic needs for food, clothing or shelter, and threatened harm to oneself or others.

    ●        The court may subpoena counseling records.

    ●        You may want to discuss further limits or exceptions of confidentiality.

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  • Caregiver Consent

  • I          (care givers name) am the legal guardian
    for          (child's name), born on   Pick a Date    (child's date of birth), and give permission for him/her/they to receive counseling services provided by Chou Hallegra (the counselor).
    In doing so, I am agreeing to the following:

    • I will communicate with the counselor regarding scheduling and any issues that may arise.
    • I will meet with the counselor as scheduled to discuss my child’s progress.
    • I will support my child in implementing the recommendations made by the counselor.



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  • Minor's Acknowledgment

  • I,         ,(minor’s name) acknowledge that my caregiver has given permission for me to receive counseling from Chou Hallegra.

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