Professional Disclosure Statement
1. SAGU Counseling Center Mission
Statement: The SAGU Counseling Center seeks to assist people
in identifying and achieving healthy solutions for their
emotional, behavioral, relational and spiritual challenges, as
well as achieving their personal growth goals. In keeping
with the mission and purpose of Southwestern Assemblies of God
University, counseling is provided from a biblical perspective
that integrates Christian values with empirically based
counseling theory, techniques, and interventions based on client
needs/goals. The Counseling Center provides
counseling and support without regard to a client's ethnicity,
gender, age, marital status or religious affiliation.
2. Staff and Qualifications: The
counseling center is staffed by Licensed Professional Counselors,
Licensed Professional Counselor Interns, and Licensed
Professional Counselor Associates. On occasion, Master's Level
Practicum students provide services under the supervision of the
Director of Counseling. Introductory information regarding
our staff is provided below. Additional information
regarding each counselor's qualifications and license numbers can
be provided upon request.
P. Randel Duncan, M.A., LPC-S
Rachel Turner, M.S., LPC-Associate (Supervised by Randel Duncan,
M.A., LPC-S)
Jennifer Gore, M.A., LPC-Associate (Supervised by P. Randel
Duncan, M.A., LPC-S)
Miami Zarauskas Smith, M.S., LPC-Associate (Supervised by
Anne Hardegree, M.Ed., LPC-S)
Michelle Butler, Practicum Student (Supervised by Randel Duncan,
M.A., LPC-S)
Angela Robinson, Practicum Student (Supervised by Randel Duncan,
M.A., LPC-S)
Mark White, M.S., LPC-Intern (Supervised by Randel Duncan, M.A.,
LPC-S)
Renay West, M.A., LPC-Associate (Supervised by Randel Duncan,
M.A., LPC-S)
Erin Gaddis, M.S., LPC-Associate (Supervised by Brenda Elledge,
M.A., LPC-S)
Counseling is a collaborative process between you and a
therapist to work on areas of dissatisfaction in your life and
assist you with life goals. For counseling to be most effective,
it is important that you take an active role in the process. The
Texas State Board of Examiners governs counseling activities for
Professional Counselors for LPC's and the Texas State Board of
Marriage and Family Therapists for LMFT's. We do not provide
custody evaluation recommendations, medication or prescription
recommendations, nor legal advice, as these activities do not
fall within our scope of practice. Benefits and Risks of
Therapy: Counseling is a process in which the client and
therapist will discuss a myriad of issues, events, experiences
and memories for the purpose of gaining insight and experiencing
positive change in working towards the client's therapeutic
goals. Benefits of counseling typically include
symptom relief, an enhanced sense of well-being, and an increased
ability to cope with peer and family relationships and/or
academic pressures. You may also gain a better understanding of
yourself which will assist in your personal development.
However, while many individuals show great benefit from
counseling, a client's experience, reactions and outcomes to the
counseling process cannot be predicted or guaranteed. The
counseling process is intentional in addressing problems that
cause internal distress and relational issues. This often results
in the client experiencing and confronting uncomfortable issues
that may lead you to feel sadness, sorrow, anxiety, or pain. In
addition, the counseling process sometimes leads to client's
making changes and major decisions which do impact other
relationships and circumstances involving family, friends or the
workplace. These decisions are a legitimate outcome of the
counseling experience as a result of an individual or couple
evaluating many of their beliefs and values. Furthermore,
symptoms may be intensified and the emotional experience may be
too intense to deal with at this time, depending on a client's
situation. Your therapist will be available to discuss any of
your assumptions or possible negative side effects in our work
together. It is important to be aware that the success of the
therapeutic relationship between you and your therapist depends
on a quality, collaborative effort. Consumer
Information/Complaints- An individual who wishes to file a
complaint against a Licensed Professional Counselor may write to:
Complaints Management and Investigative Section; P.O. Box 141369;
Austin, Texas 78714-1369; or call 1-800- 942-5540 to request the
appropriate form or obtain more information.
An individual who wishes to file a complaint against a Licensed
Marriage and Family Therapist (LMFT) or a Licensed Marriage and
Family Therapist Associate (LMFT Associate) may write to:
Complaints Management and Investigative Section, P.O. Box
141369. Austin, Texas 78714-1369 or call 1-800-942-5540 to
request the appropriate form or obtain more information.
Office Policies
6. Counseling Setting: Counseling
is conducted at the SAGU Counseling Center offices located at:
Bridges Hall, First Floor, 1200 Sycamore Avenue, Waxahachie,
Texas 75165.
7. Appointments: Individual
appointments are typically scheduled for 50-minute segments, but
can be different based on recommendations from your counselor.
Your appointment time is held exclusively for you. Please arrive
on time as you use your own time when you are late.
Length of Therapy- The number of sessions depends on many
factors and will be assessed and discussed with you. Therapy will
be terminated when goals have been achieved and by mutual
consent. An exit session, or termination interview will be
conducted at the end of therapy. You have the right to terminate
therapy at any time
Cancellations: A personal commitment is crucial to the
success of counseling. Please keep all of your scheduled
appointments. However, if you find it necessary to cancel an
appointment, please contact the office at 972.825.4721 as far in
advance as possible so that we may provide your appointment time to
another person.
Confidentiality: The information you share
will be held confidential. I will ask you to sign a release of
information form before disclosing any information obtained from
your sessions or in writing to any other person or agency,
including family members. State law and the ethics of our
profession protect your confidentiality, except in the following
cases.
The legal exceptions to confidentiality include, but are
not limited to, the following:
- If you
make a serious threat to harm yourself or another person, the law
requires your counselor to try and protect you or that other
person. This notification may include notifying the victim,
notifying the police, or seeking appropriate hospitalization.
- If I
believe a child, elder, disabled person, or dependent adult has
been or will be abused or neglected, I am legally required to
report this to the authorities.
- If you
send a health insurance claim form to your insurance for
reimbursement, it will have a mental health diagnosis label and
will become part of your permanent medical record. This may be
relevant in situations where your medical record is necessary
such as, but not limited to, qualifying for insurance, such as
life, health, or disability insurance. I may also be required to
provide additional details about the nature of your sessions to
support medical necessity.
- In order
to provide you with the best service, I may consult with other
mental health professionals about your case without revealing
your identity.
- If you
are working with a Licensed Professional Counselor Intern or
Master's level practicum student, your therapist is required to
discuss your case on a regularly scheduled basis with his/her
Supervisor. The Supervisor is also required to maintain
confidentiality. Practicum students are supervised by the
Director of Counseling Center. LPC Intern supervisor
information is listed with your counselor's qualifications within
this informed consent.
If any situation arises that necessitates disclosure of
confidential information, your therapist will make every effort
to fully discuss it with you before taking any action and will
limit disclosure to what is necessary. If you are under 18, your
parent or legal guardian(s) may have access to your records and
may authorize release to other parties. If I run into you outside
of the counseling office, I will protect your confidentiality and
wait for you to acknowledge me should you choose to do so.
A counselor's notes and any other written information regarding
your contact with the Counseling
Center never become part of your college record and are
accessible only by Counseling Center
staff. Counseling files are maintained at the SAGU Counseling
Center for 5 years after the student's
graduation or departure from school and then destroyed. With your
written authorization, counseling information can be disclosed to
a third party for the specific purpose stated in your
authorization. However, there are
certain circumstances where the Counseling Center has the right
to deny your request.
You may request to review your counseling records by filing a
written authorization with the Director of Counseling Center.
Your request must be responded to within a reasonable period of
time. If the Director and your counselor believe that review of
these records would be detrimental to your health or well-being,
the Counseling Center reserves the right to require that a member
of the Counseling Center staff be present while you review the
file in order to discuss or help interpret information contained
in the file.
10. Electronic Transmission: I cannot ensure the
confidentiality of any form of communication through electronic
media. Personal content sent via email is not secure and can be
potentially compromised. Therefore, by signing this consent
form, you are acknowledging that the Counseling Center will not
be held liable for personal information that you as the client
choose to send via email or text should your confidentiality be
compromised. You also understand that emails should only be
used for scheduling or exchanging information pertaining to
appointments. The Counseling Center will not respond to personal
content sent via email unless it is requested. Should you need to
speak with your counselor in-between sessions regarding topics
other than scheduling, you agree to do so by phone.
Records: Client records are held according to Texas
State Board of Examiners Professional Counselors - code of Ethics
Subchapter C. (681.41) or according to Texas State Board of
Marriage and Family Therapists. Your therapist is required by
law to maintain records of each time you meet or talk on the phone.
These records include a brief synopsis of the conversation along
with any observations or plans for the next meeting. If records are
requested for any purpose, our policy is to provide an appropriate
summary, as records can be misinterpreted.
12. Release of Information: If information
needs to be released it will only be done according to state law
and with a written consent from the client indicating an informed
consent of such release. In the case of marital therapy, the
client is the couple, not individuals; therefore, all records can
only be released when both parties consent in writing or if
mandated by the court. Additional information is
provided in our Privacy Policies document.
13. Incapacitation/Death: I acknowledge that, in the
event the undersigned therapist become incapacitated or dies, it
will become necessary for another therapist in the Counseling
Center to take possession of my file and records. By signing this
information and consent form, I give my consent to allowing the
Director of the Counseling Center to assign my records to another
counselor and provide me with copies upon request or to deliver
them to a therapist of my choice.
Fees and Payment: Counseling Center are provided free of
charge for students, staff, and faculty of Southwestern Assemblies
of God University. In such case that a client needs a
referral to an outside provider, the client will be responsible for
fees and payment to that provider.
15. Video/Audio Taping of Sessions: In order
to provide the highest level of care to clients, your counselor
may request to audio or video record your sessions for review and
consultation. This information will be kept confidential and you
will be informed of any intent to record a session and may
decline at your discretion.
16. Therapist Availability/Emergency Information: It
is our desire to serve you in the best possible manner. For
needs outside of sessions, such as scheduling or other concerns,
please contact the office at 972.825.4721. We attempt to
return non-emergency calls within 24 hours. If you
experience an emergency situation for which you feel immediate
attention is necessary, we will attempt to accommodate a short
notice appointment. However, if that is not possible or the
circumstances require immediate intervention, you should notify
your Resident Assistant and Dorm Pastor. If you live off
campus, you may contact Campus Security at 972.923-5400 and
request to speak with the Counselor-on-Call. Calls to Security
are recorded and logged, but you do not need to identify yourself
when requesting to speak to the Counselor-on-Call. If a
situation is possibly life threatening, please contact emergency
services (911). Please do not use e-mail, text, and faxes for
emergencies.
17. Your First Appointment: During your first visit,
you will spend time with a counselor discussing your immediate
concerns. This will help both you and your counselor decide
how Counseling Center can best assist you. These services
may consist of individual counseling, marital counseling, group
counseling, or psycho-educational classes. In some instances, you
may be referred to an off-campus service for longer-term,
intensive therapy or some other mental health expertise not
offered through the Counseling Center.
18. Litigation Limitation: Due to the nature of the
therapeutic process and the fact that it often involves making a
full disclosure with regard to the many matters which may be of a
confidential nature, it is agreed that should there be legal
proceedings (such as, but not limited to, divorce and custody
disputes, injuries, lawsuits, etc....), neither you (client's)
nor your attorney's, nor anyone else acting on your behalf will
call on your counselor to testify in court or at any other
proceeding, nor will a disclosure of the psychotherapy records be
requested unless otherwise agreed upon. If you do become involved
in litigation requiring your counselor's participation, you will
be expected to pay for the professional time even if your
therapist is compelled to testify by another party.
19. Social Media Policy: To protect the boundaries
of our relationship no connection will be created to any
counselor's personal social media account such as Facebook,
Twitter, LinkedIn, etc. However, we do have professional business
pages available to remain connected with the counseling center.
20. Minors: Minors must have parental consent
for counseling with the exception that the client: is 16 years of
age or older and resides apart from the parents/guardians and
manages his/her own financial affairs; is thinking about suicide;
has concerns about alcohol or drug addiction/dependency; or is
being sexually, physically, or emotionally abused. Consenting
parents have the right to examine the treatment records of
children under the age of 18; however, in order that minors may
have the trust of a protected environment, it is your counselor's
practice to ask parents to forego that right (they are willing to
discuss progress with the parent/guardian) with the exception of
extreme circumstances (see confidentiality
above). At the termination of treatment and
upon request, your Counselor will provide the
parent(s)/guardian(s) with a summary of treatment. It is
important to note that in the state of Texas children under 17
may not have consensual sex (by law it is considered indecency
with a child and therefore "child abuse'') and the state requires
a therapist to breach confidentiality and report such activity to
Child Protective Services. If your counselor is required to make
such a report to CPS about your child, you will be informed as
well.
21. Professional Consultation. Professional
consultation is an important component of a healthy psychotherapy
practice. As such, your therapist may participate in
clinical, ethical, and legal consultation with appropriate
professionals. During such consultations, your therapist will not
reveal any personally identifying information regarding you or
your situation.
22. Termination/Referrals: The length of your
treatment and the timing of the eventual termination of your
treatment depend on the specifics of your treatment plan and the
progress you achieve. If at any time you determine you want
another professional's opinion or wish to consult with another
therapist, you therapist will assist you in finding someone
qualified, and with your written consent, will provide him or her
with the essential information needed. You have the right to
terminate therapy at any time.
23. HIPAA/HITECH: The Counseling Center is
required by law to maintain the privacy of and provide
individuals with a copy of our "Notice to Privacy Practices" of
our ethical and legal duties in regards to your protected health
information in all forms (i.e. all paper and/or electronic data).
A copy of this notice is on our website, attached with this
informed consent and available in paper form. A copy will be
provided to you at no cost upon your request. . If you have
any objections to the Notice, please ask to speak with our
HIPAA/HITECH Certified Office Administrator in person or by phone
at our main phone number.
I have read, understood, agree, and consent to the above
conditions of service stated. I have also received the notice of
privacy practices on this date and have had the opportunity to
ask questions about and understand these policies.
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