Introduction

Counseling Partners of Los Angeles (CPLA) offers a comprehensive school-based counseling program and support services, providing the tools, support and oversight essential to ensure the greatest opportunity for every student to grow toward their full potential emotionally, intellectually, morally and socially. CPLA strives to have students, parents, teachers, and counselors actively involved in nurturing student’s success and wellbeing by providing an exceptional level of support, expertise and oversight. CPLA is committed to success for every student every day.

There is no additional cost for counseling services as it is one of the programs offered by your school. The counselors see students that are referred by faculty, parents, and the students themselves. Counseling services can benefit any psychosocial concerns involving academic, social, or emotional issues.

Contact a Counselor

You may contact the school and ask to speak with a CPLA counselor. You can also complete an electronic/online referral form and a CPLA counselor will contact you. By completing and signing this Informed-Consent form you are permitting a CPLA counselor to provide counseling services.

Background/Notification of Supervision

CPLA is a training agency for a number of universities. Our counselors have a passion for helping children and adolescents and are very excited to work with your school. CPLA counselors are graduate level students completing Master’s or Doctoral level degrees. Some are also post-graduate level associates obtaining the licensure requirement. All pre-licensed counselors are under supervision from our licensed clinical supervisors. They receive weekly supervision and regularly scheduled training. You will be informed of the name and license number of the clinical supervisor for your reference.

Provision of Services

It is the policy of CPLA to obtain written permission for counseling that extends beyond one session in a school year or that is planned on a regular basis. Services include intake assessment, short-term individual counseling, crisis intervention, group counseling, and outside referrals as needed. I understand that school counseling services are aimed at the more effective education and socialization within the school community.

I understand that these services are not intended as a substitute for psychological counseling, diagnosis, or medication, which are not the responsibility of a CPLA counselor. I acknowledge that it is my responsibility to determine whether additional or different services are necessary and whether to seek them for a student.

Benefits/Risks

I understand that there may be both risks and benefits associated with participation in counseling. Counseling may improve the student’s ability to relate to others, provide a clearer understanding of him/herself, along with values, goals, and an ability to deal with everyday stress. I understand that counseling may also lead to unanticipated feelings and change, which might have an unexpected impact on him/herself and their relationships.

Records

Records are retained by CPLA and do not become a part of a student’s school file. Records are stored safely with attention to privacy.

Telehealth in Service Delivery

CPLA counselors have the option of providing Telehealth services as needed and when appropriate in order to meet the counseling needs of our partner school communities. Telehealth is a collection of means or methods for enhancing health care, public health, and health education delivery and support using telecommunications technologies. Telehealth encompasses a broad variety of technologies and tactics to deliver virtual medical, health and education services. Telehealth is not a specific service, but a collection of means to enhance care and education delivery.

I understand that Telehealth based services and care can be as effective as face-to-face services. I also understand that the counselor with consultation will determine the best service delivery methods including face-to-face and telehealth for the student’s counseling needs. I understand that I also have the right to request and choose a mental health professional in the community who can provide a specific model of service delivery.

I understand that the student has a right to confidentiality with Telehealth under the same laws that protect confidentiality during in-school, in person CPLA counseling. I further understand that there are risks unique and specific to Telehealth, including but not limited to, the possibility that their therapy session or other communication by the CPLA counselor to others regarding the student’s treatment, could be disrupted or distorted by technical failures, or could be interrupted, or could be accessed by unauthorized persons. I understand that I can withdraw my consent to Telehealth communications by providing written notification.

CONSENT TO EXCHANGE CONFIDENTIAL INFORMATION WITH THE SCHOOL

Counseling Partners of Los Angeles works in collaboration with the school to support the student’s academic success and emotional wellbeing. Part of this partnership is the ability to exchange student information which are essential in monitoring student’s school performance and counseling progress. By signing this document, CPLA will only disclose information listed below and apply the minimal information necessary practices.

I [Name of Authorized Person to Consent for Student Under the Age of 18] ______________________________

hereby authorize Counseling Partners of Los Angeles (CPLA) and its staff to exchange information in the course of the treatment for [Full Name of Student and Birth Date]

________________________________________________ with: ______ School and its staff.

This exchange of information and records authorized herein is for the following purpose:

▪ Service Coordination and Treatment Planning

Such disclosure shall be limited to the following specific categories:

▪  Counseling information

▪  Psycho-educational testing

▪  Educational information

▪  Medical information

▪  Other

This authorization shall remain valid for one (1) calendar year from the signature date or until the authorized person revokes this consent. Any cancellation or modification of this authorization must be in writing.