Counselor Preparation Program
Permission to Participate in Counseling Exercise
Students enrolled in a counselor preparation course often participate in counseling-type situations with
volunteer clients or for research purposes in gathering information on a particular topic. As in an actual
counseling situation, confidentiality is still guaranteed. Information gained from this exercise will only
be shared with the course Instructor/supervisor who is a licensed mental health counselor, and possibly
with the other students enrolled in the current course. Participation is voluntary, and can be discontinued
at any time without penalty.
I understand that if I have any questions or concerns, I may contact the course Instructor, Dr. Carol Brennan at the College of Arts and Sciences, University of the Southwest (800-392-6561 ext. 2174). With an understanding of the above course requirement and protocol, I agree to participate and/or give permission for my child/adolescent to participate:
Parent's name:_______________________ Child/Adolescent's name:___________________________
I hereby release my student counselor and USW Counselor Preparation Program from liability.
___________________________________ ___________________________________
Parent Signature Date
__________________________________ ___________________________________
Teen Signature Date
___________________________________ ____________________________________
Witness Date