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This is an electronic copy of the UC Irvine Counseling Center Information and Consent for Services Form. The legal consent for services will be signed at the time of your scheduled first appointment. 

UCI Counseling Center  

Information and Consent for Services 

 

Welcome to the UCI Counseling Center. Our goal is to promote your health, growth, and well-being.  Please review and sign this document as it describes important issues related to the services we provide.  We will be happy to discuss any questions or concerns you may have about this information. Please let us know if you have any disability-related needs. 

 

Counseling Center Providers  

Clinical services are provided by licensed psychologists, licensed clinical social workers, postdoctoral psychology fellows, doctoral-level psychology interns, and psychology doctoral program practicum students. Counseling Center staff members work as a team and consult, as needed, among Counseling Center staff about the best way to provide the assistance that you might need. The Counseling Center is a training site for psychologists. If you are seen by a postdoctoral fellow, intern, or practicum student, you will be advised of this before your session commences. Trained student peer educators and COACHES, who are involved in the delivery of outreach programs and one-on-one coaching meetings, are also part of our staff. The peer educators and COACHES do not have access to any information about any individual’s clinical services in the Counseling Center. 

 

Eligibility for Counseling Center Services 

Enrolled UCI students, who have paid the Student Services Registration Fee, are eligible for our services. The Counseling Center does not collect fees or bill insurance for our services.  The school-sponsored Student Health Insurance Plan (SHIP) covers mental health services outside of the Counseling Center.  For relationship counseling (e.g., conjoint counseling), all participants must be enrolled UCI students. 

 

Clinical Services Provided 

We are a comprehensive Counseling Center. Our services include initial assessments, short-term individual therapy, relationship/conjoint therapy, group therapy, single session therapy, crisis care services, referral and resource visits, case management services, and comprehensive psychological assessments. 

You may choose to connect directly to our single session therapy or our referral and resource services.  For other services, your initial therapy session is an assessment to identify your concerns, develop a treatment plan, and determine whether the Counseling Center can meet your needs. Because short-term services are not an appropriate approach for all issues, we may recommend more open-ended treatment with a community provider or agency. In this case, we can help you find an appropriate off-campus provider or agency, who may be better able to meet your needs.

Regardless of the services you seek, when you meet with your provider, you will be asked questions related to your emotional and physical well-being. It is important to provide accurate and complete information so your provider can recommend the most appropriate services for your needs. 

 

Potential Benefits and Risks of Therapy 

Therapy has many potential benefits. It often leads to better relationships with others, improved academic performance, increased coping abilities, solutions to specific problems, and/or reduced feelings of distress. However, the therapy process may include discussion of personal challenges and difficulties. These discussions can elicit uncomfortable feelings such as sadness, guilt, anger, fear, and frustration. At times, therapy may also unfavorably impact relationships with others. Please discuss any concerns you may have with your provider. 

There are many different approaches that can be utilized to address your concerns. Therapy requires collaboration and effort on your part. In order to be maximally successful, your active participation both during and in between your sessions is necessary. Results of treatment cannot be guaranteed. 

 

Urgent Situations During and After Hours 

If you have an emergency where you or someone else is at risk of serious harm, call 911, call the UC Irvine Campus Police at (949) 824-5223, or go to the nearest emergency room. For other urgent situations, please come to the Counseling Center during our lobby hours or call (949) 824-6457 during business hours to speak to your assigned therapist (or to the crisis care therapist if your assigned therapist is not available). For after-hours urgent needs, call our front desk at (949) 824-6457 and select option # 2 to speak immediately with a mental health professional.  

 

Potential Request for Audio or Video Recording  

The Counseling Center is a training agency.  Your provider may request to audio or video record your sessions for the purpose of ensuring quality service provision, continued staff training, and clinical supervision.  You have the right to decline being recorded. Your therapist can address any concerns you may have about recording. 

 

Confidentiality and Limits to Confidentiality 

In keeping with ethical standards of the Counseling Center mental health providers, as well as California and federal laws, all services provided by Counseling Center staff and the records of these services are confidential to the extent allowed by law.  

There are exceptions which include, but are not limited to the following: 

• If you provide written permission and request that we share information about the services you receive, the Counseling Center staff will share appropriate information with the designated people or agencies. 

• We consult as needed among Counseling Center staff about the best way to provide the assistance that you might need. 

• Counseling Center staff members will share information about your services and/or your treatment records with your other mental health and/or health care providers when your Counseling Center provider believes that you are experiencing a mental health, health or safety emergency and that sharing information will be beneficial to you.  

• Your clinical records may have less protection from a subpoena if they are disclosed to someone who is not a treatment provider (e.g., to yourself, a faculty member, another campus office, or a family member). 

• The Counseling Center shares an electronic medical record system with the UCI Student Health Center, UCI Campus Assault and Resource Education, UCI Campus Social Workers, the Assistant Vice Chancellor of Wellness Health and Counseling, and Faculty and Staff Support Services. The following specific fields of your electronic counseling record may be visible to all of the above offices: your medications, allergies, problem lists, referral forms, and some letters from your providers.  

• Aggregated, deidentified data from client records may be used for research purposes as allowed by state and federal law (e.g., client utilization data, clients’ top concerns).  

• Some administrative functions (such as technical maintenance, quality assurance, performance improvement, risk management, clinic/center operations, and professional audits) require access to our client records by Counseling Center staff members and affiliated professionals/entities.  UC Risk Management is one of the affiliated entities which may require access to our records for review in the event of certain incidents. Counseling Center staff members and affiliated professionals/entities maintain confidentiality within their jobs. 

• The Counseling Center professional staff have ethical and/or legal responsibilities to disclose client information without prior consent when: 

• a client is likely to harm themselves or others a client is gravely disabled (i.e., lacks the capacity to care for self)  

• there is a reasonable suspicion of abuse of dependent adults, the elderly, or children. Abuse of children includes developing, sharing, or accessing child pornography. 

• there is a valid subpoena or court order for the disclosure of client information and/or records  

• Note: Some court orders require the Counseling Center to abstain from notifying the client of the release of clinical information and/or records.

 

Minors and Confidentiality 

If you are a minor, your provider is required to involve your parent/guardian in therapy, unless the provider makes a professional judgment that parental/guardian involvement is determined to be inappropriate.  The level of involvement, as well as the amount of information shared, is decided on an individual basis. Please discuss any concerns you have about parental/guardian involvement and/or access to information about your therapy. 

My Access to my Counseling Center Records 

UCI Counseling Center is legally required to make your relevant clinical notes available to you on the Wellness, Health and Counseling student portal. Potential benefits of accessing your clinical notes through the portal may include, but are not limited to, more immediate access to your records, the opportunity to track your progress in treatment, and the ability to view your record for accuracy. While most clients respond positively to this option, some do not. Please know that you are able to opt out of having access to these notes on the portal. 

When determining whether you want portal access to your records, it is important to consider implications regarding confidentiality. For example, if you have given a parent or partner your portal access information, they would be able to see your clinical notes. If you have concerns, you may discuss these with your provider to determine the content of notes and if you would like to opt out of portal access. 

The student portal’s default setting automatically gives you access to your records. If you want to opt out of making your records accessible on the student portal, please discuss this with your therapist before your first appointment ends or at any time during treatment. 

Regardless of whether your records are accessible on the portal, you may also obtain copies of your records by calling 949-824-6457 or stopping by the Counseling Center to make a request. For this process, you will need to complete a written authorization to release your records to the person of your choice. Your request will be fulfilled within 15 business days, but sooner whenever possible. 

Communication with Your Provider 

If you need to communicate with your provider between sessions, please do not use email, as email is not a secure and confidential form of communication.  Instead, please call our main number to connect to your provider by phone or use the secure online messaging system found at https://osh.shs.uci.edu/. Examples of appropriate reasons to send a secure message to your provider include scheduling, rescheduling, or following up on referrals. Secure messaging is not to be used as a replacement for an appointment, nor as a means of online psychotherapy. Do not use the message system for urgent communications.  For urgent needs, please follow instructions in the “Urgent Situations During and After Hours” section above.  

 

Knowing your Provider from a Different Setting 

We are mindful of multiple roles that could impact the therapy process. If you are assigned to a provider whom you know through another setting (e.g., your provider is teaching your class), please let our front desk staff know that you need to be assigned to another provider.  

 

Client Rights and Responsibilities 

Access to Services  

• Eligible students may receive an initial assessment of their concerns to determine appropriate treatment recommendations. Additionally, students may utilize our crisis care or after-hours services for urgent and/or crisis situations. Any additional services are determined based on the provider’s treatment recommendations. 

• If you consider your situation to be urgent or an emergency, please inform our staff when you request an appointment. 

Missed Appointments and Cancellations 

• You are expected to arrive on time for your appointments. If you arrive more than 10 minutes late for your session, your appointment may need to be rescheduled. 

• If you are unable to keep your appointment, please call to cancel as far in advance as possible so that we can offer the appointment to another student. Cancellations must be made with 24 hours advance notice. Any late cancellations or missed appointments may be counted as No Show Appointments and impact your access to future appointments.  

 Compliance with Treatment Plan 

Your provider will use clinical judgment to develop a treatment plan based on the background information you provide along with your input about treatment goals. It is your responsibility to adhere to the treatment plan to maximize treatment benefits. If you disagree with your treatment plan, please discuss alternatives with your provider(s).  

Appropriate Conduct 

• We strive to create an emotionally and physically comfortable and safe environment for all people present in the Counseling Center. You are expected to treat all members of the Counseling Center staff and all Counseling Center visitors with respect.  

• The Counseling Center may refuse services due to disruptive behavior. 

• Personal cell phone use, videos, and photographs are prohibited in the Counseling Center common areas. If you wish to use your cell phone for any of the above purposes during your session, please discuss with your provider first. 

Termination of Services  

• It is helpful to discuss your intention to end services with your counselor in advance of termination when possible.  Please notify your counselor if you plan to discontinue services or if you do not plan to return. 

• The Counseling Center may also terminate services due to repeated late cancellations, multiple missed appointments, disrespectful behavior, and/or failure to comply with the treatment plan. 

Feedback about Services 

• If you are dissatisfied or have concerns about the services you received at the Counseling Center, please bring this to your provider’s attention if possible.  Often a conversation about these concerns can provide useful feedback to help the provider change to an approach that will be more helpful to you. 

• If you feel unable to discuss your concerns with your provider and would like assistance addressing the concerns, please contact the Counseling Center Clinical Director or Director, who can be reached at 949-824-6457.  

• If you wish to make a complaint, please contact the Counseling Center Quality Assurance Director, who can also be reached at 949-824-6457. 

• Other feedback can be submitted anonymously via our online survey, accessible on the Counseling Center website. 

If you have questions or concerns about the information and conditions described above, please discuss them with your provider before signing this form. 

Version: June 2024