The Counseling Office is committed to ensuring that you receive professional services directed toward

your needs in a manner that protects your dignity and feelings of self-worth. To this end, the following Statement of Rights has been formulated.

DISCRIMINATION

Services will be provided to you without discrimination. Ethnic background, personal or social creed, gender, religion, age, or sexual orientation will not affect our service to you.
You will not be refused any services based on lack of, or limited, personal financial resources. Inconveniences for time away from work or class will be discussed and kept at a minimum. Every effort will be made to ensure that physical barriers do not preclude services.

CONFIDENTIALITY

All information concerning you is held confidential and released only through procedures consistent with the law and professional ethics. Federal law requires that those receiving treatment for drug or alcohol abuse be advised of the following statements: The confidentiality of alcohol and drug abuse patient records maintained by this program is protected by Federal law and regulations. Generally, the program may not say to a person outside the program that a patient attends the program, or disclose any information identifying a patient as an alcohol or drug abuser UNLESS:
1. The patient consents in writing,
2. The disclosure is allowed by a court order, or
3. The disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation.

Violation of the Federal law and regulations by a program is a crime. Suspected violations may be reported to appropriate authorities in accordance with federal regulations.

Federal law and regulations do not protect any information about a crime committed by a patient either at the program or against any person who works for the program, or about any threat to commit such a crime.

Federal law and regulations do not protect any information about suspected child abuse or neglect from being reported under State law to appropriate state or local authorities.

You have a right to review and approve any information being requested by another provider giving service to you. You must sign a release for any such information sent.

CONSENT FOR SERVICES

I hereby request services at the Vincennes University Jasper Counseling Office. I understand that all information regarding my contact with the Counseling Office is confidential and will not be released without my knowledge and consent, except where required by law. I understand my counselor may divulge confidential material as required by the State (for example, to report suspected child abuse or neglect), or if I express serious intent to harm myself or others. I have reviewed this Statement of Rights and have no questions regarding such.

Consent to Treat - Statement of Rights