Consent

Information for Adults

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It takes lots of courage to see a counsellor. I believe it is important to be open
about what counselling is all about so I would like to tell you some things about my
job as a counsellor and what to expect from our time together. I will answer any
questions you have about counselling!1


My name is Molly Hayes and I am a Masters of Counselling student from the University of
Lethbridge. I am honoured to be a part of your familys experience with the Calgary Catholic
School District (CCSD) counselling services and I look forward to the opportunity to help you
meet your counselling goals. With your permission, I have the chance to work with you this
school year. You may have already consented to the involvement of Instructional Services for
extra psychological and learning help but the purpose of this form is to give you more
information about what counselling with me could look like so that you can make an informed
decision about working with me.


I am dedicated to ensuring that every parent I work with has a safe place to explore his/her
goals for change the way that they want. What that means is
Talk about what you want (and how you want)
Share a little or a lot
You can say NO or STOP to ANYTHING we suggest including counselling entirely
You can see another counsellor if you want
You can ask questions at any time






1 I borrowed some of the information and/or wording of this section, with permission, from a consent form originally written by

Consent Information for Adults

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I am in my final year of the Masters of Counselling program and I completing my counselling
practicum with CCSD this school year. All of my work is supervised by a very experienced CCSD
psychologist named Wes Bartel. I have listed my contact information as well as Wes at the end
of this document; you are welcome to contact either of us regarding the counselling process. I
am supervised to ensure that your family gets the best treatment possible with CCSD. I have
attached an additional document that provides more specific information about supervision for
you to review.


Like the psychology professionals at CCSD and my university that supervise and teach me, I too
adhere to the Canadian Psychologists Code of Ethics. Protecting your familys privacy to these
ethical standards is extremely important to me. What this means is that I will not talk to anyone
about your issues or your familys issues (including teachers and principals within the district).

To track progress, I keep brief session notes. You have the right to see my notes. Digital copies
of my notes are stored in password-protected documents within the districts network. Paper
copies of my notes are stored in a locked filing cabinet in a locked office.

The Canadian Psychologists Code of Ethics outlines some situations where your counsellor
might have to tell someone something about you or take action:
If you tell your counsellor about vulnerable people (children and adults) who are being
harmed, abused, neglected or are a witness to abuse.
You are in imminent danger of hurting yourself or someone else, or you know of someone
who is in danger of getting hurt.

Your counsellor also as a moral obligation to tell the appropriate authorities if you tell them
about:
Maltreatment of clients by a helping professional
Criminal activities (past or current)

Consent Information for Adults

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Counselling is about sorting through your experiences and finding a way of handling situations
that works best for you. The benefit of counselling is that it might make you feel better (thats
the idea!). Counselling has specific goals and although I will do my best to support you, this
experience might be challenging. You might feel tired or upset after a session this can be
because taking on a new way of looking at your life can be tiring or because weve talked about
a tough topic. Counselling might not be the only thing that can help. Other forms of treatment
include physical activity, support groups (religious, spiritual or other) and medication for
psychological symptoms. If you want to talk about any other options, let me know.



If you decide that you would like to use me for extra help, I can become your counsellor. What
that means is that I cant
Buy things from you
Accept gifts from you
Be your teacher, instructor, or evaluator
Give you advice (financial, business, or otherwise)
Touch you (anything more than a handshake or a high-five is a no-go for us)
Accept invitations to events

Consent Information for Adults

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Consent for Counselling

My signature below signifies that I understand the information in this consent form and that I
am being asked to give my permission for my child to seek extra help through counselling.
The following documents mentioned in this consent form must
Have you been given these
be given to you for review:
documents to read?
Consent Information for Adults (thats this document!)

University of Lethbridge consent form for supervision and
YES or NO
recording

You deserve the chance to ask questions about the counselling

process and about giving consent.

Have your questions been

answered to your
satisfaction?

YES or NO

I, ___________________________________________ give permission to be involved in

counselling with Molly Hayes.


______________________________
Parent/Guardian Name (print)


______________________________
Parent/Guardian Name (print)


______________________________
Parent/Guardian Name (print)


______________________________
Parent/Guardian Name (print)

_____________________________
Parent/Guardian Signature


_____________________________
Parent/Guardian Signature


_____________________________
Parent/Guardian Signature


_____________________________
Parent/Guardian Signature

Graduate Student Counsellor signifying that consent has been obtained:

______________________________________________________________

_______________
Date


_______________
Date


_______________
Date


_______________
Date

______________
Date

You can contact me at molly.hayes@cssd.ab.ca or 403 500 2002 or my supervisor, Wes Bartel at
wes.bartel@cssd.ab.ca or 403 500 2619