Treatment with Intern Informed Consent Form

Pediatric and Adult Behavioral Counseling is dedicated to empowering our clients to a place of new possibilities through a process of healing and growing within a supportive and compassionate environment. As a part of our efforts to ensure that quality care is provided to all our clients, we encourage student interns to observe sessions by therapists as a part of their internship experience. If you agree to this process, which will both serve the intern’s training needs and enrich your personal counseling experience via the added perspective of supervisory review.

Student Interns are under the supervision of Pediatric and Adult Behavioral Counseling Clinical Supervisors:

Dennielle McIver, MS LPC-S NCC or Dawn Revyn, MA Ed LPC-S

whom are bound to the ethical guidelines of the American Counseling Association and adhere to the guidelines specified by The National Board for Certified Counselors, Inc. and Affiliates;  as well as insurance service agreement, Telehealth Service Consent, Internship Supervision Agreement of their educational institution and Notice of Privacy Practices / HIPAA.

Student interns have completed the required education and competencies necessary to be deemed ready to apply their clinical skills to working with clients. The intern receives ongoing guidance, evaluation, and education in providing excellence in clinical skills to you and/or your family members. By working with a student intern, you receive the benefits of a clinically experienced supervision team assisting in assessment and treatment planning to address your concerns in therapy.

Student interns may observe counseling sessions in conjunction with a fully and/or limited licensed clinician, and when deemed ready by Pediatric and Adult Behavioral Counseling, may provide counseling services without a supervising clinician present.

Sessions conducted by student interns may include recording of sessions, for use in supervision. Recordings may not be used for any other purposes than for use in supervision, are stored on a password protected device and are destroyed at the termination of therapy.

Limits of Confidentiality

Confidentiality will conform to state guidelines and the ethical guidelines of the American Counseling Association. All interns, their supervisors, and group supervision members will not disclose information except under the following conditions:

  • The client or guardian gives written consent to release information to a designated individual or agency;
  • The client makes specific violent threats to harm him-or herself or to harm an identifiable victim;
  • The intern and/or their supervisors are named as defendants in a civil, criminal, or disciplinary action arising from the counseling session;
  • The intern receives an authentic subpoena backed by judicial authority that requires the disclosure of information;
  • The intern has reasonable cause to believe that a child or adult with a disability has suffered abuse or neglect; and
  • The intern will discuss the content of counseling sessions in individual and group supervision under the direction of a qualified supervisor who is held to the same professional standards of confidentiality and its limits.

Authorization of Participation and Services by Student Intern

This consent remains valid for two years unless the client* or legal representative** withdraws his/her consent by written notification or the client is discharged from services.
This consent remains valid for two years unless the client* or legal representative** withdraws his/her consent by written notification or the client is discharged from services.
* Please check below if you consent to participate and support our program that allows our student intern to observe and/or provide services to you or your child’s therapy sessions and to gain practical experience.
* Please check below if you consent to obtain therapeutic services from our student intern at a reduced fee rate of $30 per 45 minute session if you choose to waive your rights to bill services to insurance, are out of network, uninsured, and/or meet criteria for reduced rate fee.
* Please check below if you consent recording of sessions conducted by Student Intern for use in supervision. Recordings may not be used for any other purposes than for use in supervision, are stored on a password protected device and are destroyed at the termination of therapy.

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By checking this, you are eSigning this form.