Assignment

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