Informed Consent & Agreement for Counselling at Selkirk College

Selkirk College Counselling Services offers academic, career, and short term personal counselling to all eligible students.

Student Name Student Name First Last
Student Number
Birthdate Birthdate / MM / DD YYYY
Which counsellor are you booked to see?
How Services are Provided: The Counselling Department is offering in-person appointments. You may also book online and phone counselling during this time, which can include consultation, treatment, emails, telephone conversations, and/or using interactive video, audio, screen sharing communications. The Selkirk Counselling Department will be using a platform called “Zoom," which allows for video and audio counselling, as well as a telephone counselling option.

Do you understand and consent to how services are provided?

How Services are Provided: The Counselling Department is offering in-person appointments. You may also book online and phone counselling during this time, which can include consultation, treatment, emails, telephone conversations, and/or using interactive video, audio, screen sharing communications. The Selkirk Counselling Department will be using a platform called “Zoom," which allows for video and audio counselling, as well as a telephone counselling option.

Do you understand and consent to how services are provided? Yes No
Risks and Benefits: Counselling itself can have both risks and benefits. The counselling process may include discussion of your personal challenges and difficulties, which can elicit uncomfortable feelings. However, counselling has also been shown to have many benefits including better interpersonal relationships, improved academic performance, solutions to specific problems and reductions in your feelings of distress. However, there is no assurance of these benefits.

There are also risks and benefits of the Online/Phone counselling platform. Virtual counselling is different than in-person counselling. It may feel incomplete or distant, and you may experience some challenges such as internet/service connection difficulties and increased chance of misunderstandings (ie. emotional, verbal, tone). However, virtual counselling can offer a more convenient space to speak to a counsellor from your home while adhering to COVID-19 social distance requirements. Your counsellor will do everything in their power to ensure that you feel comfortable and heard during your counselling experience. Always feel free to ask questions!

Do you understand the risks and benefits?

Risks and Benefits: Counselling itself can have both risks and benefits. The counselling process may include discussion of your personal challenges and difficulties, which can elicit uncomfortable feelings. However, counselling has also been shown to have many benefits including better interpersonal relationships, improved academic performance, solutions to specific problems and reductions in your feelings of distress. However, there is no assurance of these benefits.

There are also risks and benefits of the Online/Phone counselling platform. Virtual counselling is different than in-person counselling. It may feel incomplete or distant, and you may experience some challenges such as internet/service connection difficulties and increased chance of misunderstandings (ie. emotional, verbal, tone). However, virtual counselling can offer a more convenient space to speak to a counsellor from your home while adhering to COVID-19 social distance requirements. Your counsellor will do everything in their power to ensure that you feel comfortable and heard during your counselling experience. Always feel free to ask questions!

Do you understand the risks and benefits? Yes No
Rights and Responsibilities: Working with a counsellor is most helpful when you are aware of the rights and responsibilities involved. Please read the following carefully:
Confidentiality: Information shared by you will be treated confidentially within the counselling services team (comprised of the five counsellors). Notes are kept in a locked room and/or on a secure server. Any disclosure we make beyond the counselling team will be done with your written or verbal permission/request, with exceptional circumstances as listed below. (*Please note that we cannot guarantee confidentiality in email messages and discourage the use of email for any reason other than booking appointments).

Do you understand confidentiality and disclosure?

Confidentiality: Information shared by you will be treated confidentially within the counselling services team (comprised of the five counsellors). Notes are kept in a locked room and/or on a secure server. Any disclosure we make beyond the counselling team will be done with your written or verbal permission/request, with exceptional circumstances as listed below. (*Please note that we cannot guarantee confidentiality in email messages and discourage the use of email for any reason other than booking appointments).

Do you understand confidentiality and disclosure? Yes No
Limits to confidentiality include:

1. If there is a serious possibility that you may harm yourself or others, we must take reasonable actions, which may include contacting college staff, the police or other responsible authorities.

2. If you are under the age of 19 and disclose abuse (sexual, physical and/or emotional) by a specific person, the abuse may be reported to the Ministry for Children and Families

3. If you are over the age of 19 and disclose abuse (sexual, physical and/or emotional) by a specific person who has access to people under the age of 19, the abuse may be reported to the Ministry for Children and Families

4. In some court actions, our professional staff and/or their records may be subpoenaed.

5. The counsellors may from time to time consult with one another regarding serious challenges you may have. This is to ensure the highest level of service to you.

6. General information from counselling sessions (e.g., gender, year) may be gathered and collated to ensure we are sufficiently meeting the needs of students, and may be distributed externally via conferences and other publications. No identifiable information will be shared. Please inform the Counsellor if you are not comfortable with this and your information will not be used.

Do you understand the limits to confidentiality?

Limits to confidentiality include:

1. If there is a serious possibility that you may harm yourself or others, we must take reasonable actions, which may include contacting college staff, the police or other responsible authorities.

2. If you are under the age of 19 and disclose abuse (sexual, physical and/or emotional) by a specific person, the abuse may be reported to the Ministry for Children and Families

3. If you are over the age of 19 and disclose abuse (sexual, physical and/or emotional) by a specific person who has access to people under the age of 19, the abuse may be reported to the Ministry for Children and Families

4. In some court actions, our professional staff and/or their records may be subpoenaed.

5. The counsellors may from time to time consult with one another regarding serious challenges you may have. This is to ensure the highest level of service to you.

6. General information from counselling sessions (e.g., gender, year) may be gathered and collated to ensure we are sufficiently meeting the needs of students, and may be distributed externally via conferences and other publications. No identifiable information will be shared. Please inform the Counsellor if you are not comfortable with this and your information will not be used.

Do you understand the limits to confidentiality? Yes No
Records: Secure counselling records are kept by the Counselling Services Team. To request a copy of these records, please forward a written request to the counsellor, which will be reviewed and responded to within 30 days. Canadian and BC Freedom of Information and Privacy requirements will be followed in processing this request.

Do you understand how to access your records?

Records: Secure counselling records are kept by the Counselling Services Team. To request a copy of these records, please forward a written request to the counsellor, which will be reviewed and responded to within 30 days. Canadian and BC Freedom of Information and Privacy requirements will be followed in processing this request.

Do you understand how to access your records? Yes No
Privacy: If you choose an online or phone appointment please note the following:

1. If you are not in a private room, there is a chance that someone can overhear you.

2. You are responsible for providing the necessary computer/phone/telecommunications equipment and internet access for your online counselling sessions

3. Arrange a location with sufficient lighting and privacy that is free from distractions or intrusions for your online or phone counselling session.

4. It is the responsibility of the counsellor to do the same on their end. Your counselling sessions are NOT recorded to ensure you confidentiality, unless there is an explicit written consent by you for reasons that clearly benefit my treatment. All Zoom voice, video, file transfers, and instant messages are encrypted. This prevents any digital eavesdroppers.

Do you understand our shared responsibility for privacy?

Privacy: If you choose an online or phone appointment please note the following:

1. If you are not in a private room, there is a chance that someone can overhear you.

2. You are responsible for providing the necessary computer/phone/telecommunications equipment and internet access for your online counselling sessions

3. Arrange a location with sufficient lighting and privacy that is free from distractions or intrusions for your online or phone counselling session.

4. It is the responsibility of the counsellor to do the same on their end. Your counselling sessions are NOT recorded to ensure you confidentiality, unless there is an explicit written consent by you for reasons that clearly benefit my treatment. All Zoom voice, video, file transfers, and instant messages are encrypted. This prevents any digital eavesdroppers.

Do you understand our shared responsibility for privacy? Yes No
Technology Challenges or Failure: In online counselling, there is a risk that services could be disrupted or distorted by unforeseen technical problems. In the event of a technology failure during a Zoom virtual or phone session immediate steps will be taken by the counsellor to reconnect. Contact via phone is the first backup step to failed Zoom reconnection, followed by emailing. The counsellor will repeatedly attempt to use these methods to contact me through the remaining session time (and I will do the same, as well). If efforts to reconnect are unsuccessful, the compromised appointment will be rescheduled, unless other arrangements are made.

Do you understand the challenges of technology?

Technology Challenges or Failure: In online counselling, there is a risk that services could be disrupted or distorted by unforeseen technical problems. In the event of a technology failure during a Zoom virtual or phone session immediate steps will be taken by the counsellor to reconnect. Contact via phone is the first backup step to failed Zoom reconnection, followed by emailing. The counsellor will repeatedly attempt to use these methods to contact me through the remaining session time (and I will do the same, as well). If efforts to reconnect are unsuccessful, the compromised appointment will be rescheduled, unless other arrangements are made.

Do you understand the challenges of technology? Yes No
Counselling and Emergencies: If you are experiencing an emergency situation, it is your responsibility to call 911 or proceed to the nearest hospital emergency room for help. If you are having suicidal thoughts or making plans to harm yourself, call Interior Crisis Line Network at 1-888-353-2273 for 24-hour phone support, text YouthSpace at 778-783-0177 for online chat support, or visit Here2Talk.ca

Do you understand your responsibility to seek emergency help for yourself?

Counselling and Emergencies: If you are experiencing an emergency situation, it is your responsibility to call 911 or proceed to the nearest hospital emergency room for help. If you are having suicidal thoughts or making plans to harm yourself, call Interior Crisis Line Network at 1-888-353-2273 for 24-hour phone support, text YouthSpace at 778-783-0177 for online chat support, or visit Here2Talk.ca

Do you understand your responsibility to seek emergency help for yourself? Yes No
Assessing and evaluating threats and other emergencies can be more difficult when conducting online counselling than in traditional in-person counselling. To address some of these difficulties, it is important that you identify an emergency contact person before engaging in online counselling services. It is preferable that this person is someone who is near you and who would be available to help in a crisis or emergency situation.

Please list your emergency contact person: Assessing and evaluating threats and other emergencies can be more difficult when conducting online counselling than in traditional in-person counselling. To address some of these difficulties, it is important that you identify an emergency contact person before engaging in online counselling services. It is preferable that this person is someone who is near you and who would be available to help in a crisis or emergency situation.

Please list your emergency contact person: First Last
Please list your emergency contact person's phone number: Please list your emergency contact person's phone number: - ### - ### ####
If you have any questions or concerns about this information, please do not hesitate to discuss these with your Counsellor.

A link to a secure online feedback survey will be sent to the email address you provide. The survey is designed to gather information to improve service delivery.
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.

Informed Consent & Agreement for Counselling at Selkirk College

Informed Consent & Agreement for Counselling at Selkirk College

Rights and Responsibilities: Working with a counsellor is most helpful when you are aware of the rights and responsibilities involved. Please read the following carefully:

If you have any questions or concerns about this information, please do not hesitate to discuss these with your Counsellor. A link to a secure online feedback survey will be sent to the email address you provide. The survey is designed to gather information to improve service delivery.

If you have any questions or concerns about this information, please do not hesitate to discuss these with your Counsellor.

A link to a secure online feedback survey will be sent to the email address you provide. The survey is designed to gather information to improve service delivery.