St. Matthew Counseling: Informed Consent Form 2021-22Purpose: This document is called an Informed Consent. The purpose of Informed Consent is to provide important information that is relevant to a counseling relationship and to also gain your written consent to work with your child(ren). Please read through the information on this form, and contact Mikaela Haney and Jennie Statczar if you have any questions or concerns.
Credentials: Mikaela Haney is approved by the State of Ohio Counselor and Social Worker Board as a Licensed Social Worker, license # S.2004831 under supervision by Ashley Daugherty, LISW-S. She holds a Bachelor of Arts degree in Psychology from Miami University and a Masters in Social Work from The Ohio State University. Jennie Statczar is approved by the State of Ohio Counselor and Social Worker Board as a Licensed Professional Counselor, license # C.2002647 under supervision by Jodi Schermerhorn, LPCC-S. She holds a Bachelor of Science Degree in Applied Psychology from Franklin University and a Master of Arts in Clinical Mental Health Counseling from Ashland Theological Seminary.
Goals of Counseling: The goal of counseling is to address and treat mental and emotional issues. They will work with your child to set specific objectives that will enable us to reach that goal.
Counseling Relationship: Individual counseling provides children with the opportunity to explore feelings, thoughts, and behaviors in a private, one-on-one setting with a trusted adult (counselor). Group counseling gives students the experience of working with two or more students under the guidance of the counselor in order to address feelings, thoughts, behaviors, and/or to learn specific skills. The purpose of both individual and group counseling is to work on academic, personal, social, and emotional issues so students will be prepared to focus on school achievement. Counseling is voluntary and without a guarantee. You or your child may stop counseling at any time without any negative consequences. At times, sensitive or difficult topics are addressed which may bring about emotional discomfort. However, dealing with these issues can lead to better understanding and acceptance of self and others. Counseling on site and virtual students will be at no cost to the families that use it. If your family decides they would like additional work those sessions would be handled at one of their outside location and will be billed through insurance or private pay. The length of the counseling relationship depends on the needs of the student. Counseling typically follows a brief model, and the focus of counseling is on the child’s strengths, successes, and progression toward their counseling goals.
Benefits and Limitations: Counseling can be very beneficial to children. Through counseling, children can realize their strengths and focus their efforts in more positive directions. Together, your child and Mikaela/Jennie can explore goals and develop plans for those goals to be met.
Counseling also has some limitations as success primarily depends upon the child working to create and attain meaningful goals. For this to happen, the child must be an active participant in the counseling relationship. If the child is unwilling to be active, counseling is likely to have minimal positive effects.
It is important to understand that counseling is not always an easy process. Children may try new ways of conducting themselves that initially feel uncomfortable, and change can produce anxiety for students. Every effort will be made to minimize these risks for students. Counseling occurs during the school day. Mikaela and Jennie will make every effort to pull the students at times when they are not academically impacted.
Confidentiality: Mikaela and Jennie have an ethical obligation to keep details disclosed by students in the counseling relationship confidential. This means that the counselor will not share this detailed information with administrators, teachers or other students without the explicit consent of the student and/or parents/guardians. Please note that because the school is the setting of these counseling sessions, Mikaela and Jennie will be providing information to the principal that will include the student’s name, date and focus of the session.
In general, some limitations exist to confidentiality. In each of these cases, Mikaela and Jennie would take all precautions required by the Ohio Revised Code to ensure the safety of the child. The limitations are as follows:
● The counselor has reason to suspect child abuse.
● There is a need to warn and protect the student or others who are in imminent danger.
● The student is planning to hurt themselves or is being hurt by another party.
● The student or guardian requests a release of information
● The counselor receives a court order requiring disclosure of information.
● If there is any complaint or litigation against the counselor that requires the release of the information.
● If there is a need to protect a third party from a communicable and fatal disease.
If any of these limitations exist, the counselor is released from the obligation to keep information confidential. Consultation with another professional will occur when a potential exception to confidentiality is ambiguous in nature. Be aware that cases will be discussed in case consultation and supervision.
Virtual Students: Students electing virtual platforms this year may use our E-Therapy platform for web-based counseling which is HIPAA compliant and does not use or leave adware, spyware, advertising, pop-ups, etc. active on your computer. E-Therapy sessions are not recorded by Spirit of Peace Clinical Counseling on any hard drives, servers, thumb drives, or any other media storage device. We are bound by law to protect your privacy and confidentiality. All other terms of this consent are in compliance with E-Therapy. http://education.ohio.gov/Topics/Reset-and-Restart/Telehealth-Guidelines-for-Service-Providers
Procedures: Students may be referred to counseling by the teacher, administrator, or parents/guardians. Mikaela and Jennie will make every effort to solicit the input of the school based personal prior to working with students. Written documentation is completed for each referral, and a file is created. After each session, students are promptly sent back to class. Documentation is then completed summarizing the meeting, and this record is stored in Therapy Notes.
Written Reports: All counseling-related materials are kept in secured files separate from the student’s cumulative file. Parents have the right to make appointments to view their child’s counseling file; however, the actual records remain the property of Mikaela and Jennie.
Professionalism: These services will be rendered in a professional manner consistent with my accepted ethical standards. If for any reason, questions come up, please do not hesitate to ask. You have a right to have your questions answered. If you do not feel like your questions are answered adequately, please feel free to contact State of Ohio - Counselor, Social Worker, and Marriage and Family Therapist Board which regulates all licensed counselors and can be reached at 77 S. High St, 24th Floor, Columbus, OH 43215.