Children's Advocacy Center
Serving Bastrop, Lee & Fayette Counties

I, the undersigned, understand that my or my child's therapist is currently providing therapeutic
services under supervision of:

Stacey Helm, LPC-S, LSOTP, NCC
LPC-S License #62725, LSOTP License #99836

Texas Behavioral Health Executive Council
George H.W. Bush State Office Building
1801 Congress Ave., Ste. 7.300
Austin, Texas 78701
Main Line (512) 305-7700
Investigations/Complaints 24-hour, toll-free system (800) 821-3205

I consent to the release of counseling session information for supervision purposes. This
supervision is a requirement for my or my child's therapist in their route to successful
completion of graduate school, professional license or other certification. Furthermore, this
supervision may be used to aid my or my child's therapist to obtain effective support and
consultation from another mental health professional.

I understand that the supervising therapist is under the same ethical and legal guidelines as other therapists, which requires information from a counseling session to be treated as confidential.

Furthermore, I understand that I have the right to refuse this request now, or at any time in the future with the understanding that a consequence may be a referral to another mental health professional. In order to revoke this consent, I know that I need to contact the CAC Clinical Director and do so in writing.