Graduate Intern/Client Informed Consent Form

We would like you to fully understand several important aspects of how we work.
Please read this and ask for clarification if necessary before you sign.

Consent to Work with a Graduate Intern

I give my permission to work with a Graduate Intern who is completing their field placement at The Counseling
Center at Roberts Wesleyan College. This permission covers the following areas:

 Counseling under Supervision – Each graduate student receives individual as well as group supervision
from a trained, licensed practitioner. If you have any questions or concerns about the intern’s work,
please contact the Counseling Center Director, Emma Wolford. The highest standards of confidentiality
remain in effect during this process.
 Review of records – May be done through the supervision process or by other Counseling Center staff
members as deemed appropriate. The highest standards of confidentiality remain in effect during this
process.
 Observing or taping of session – Audio-taping and/or video-taping of sessions may be used to monitor
the quality of counseling skills; the tapes are always maintained confidentially and are not used for any
other purposes. If either of these policies are of considerable concern to you, please discuss it with your
counselor at the beginning of your appointment, and we will attempt to make other arrangements.
Your consent to these arrangements will remain in effect for one year from the date signed below. If you have
any comments or exceptions you would like to make to this consent, please do so in the space provided below.
Client Comments Regarding Consent:

Client Consent
When you have read to this point and have asked for clarification if necessary, please read the paragraph below
and sign.
I have read and understand the statement above; my signature below indicates that I give full and informed
consent to receive services from a Graduate Intern. I understand that I have the right to revoke this
permission at any time as well as the right not to authorize this disclosure.

Client Date

Counselor Date