I understand that as a registered student of Cal Poly I am eligible to receive services at Counseling Services free of charge. I understand that CAPS provides crisis services, individual, couples and group therapy. The type and extent of services that I receive will be determined following an initial assessment and discussion with me. I understand that I must provide accurate and complete information in order for my mental health professional to be able to make a relevant assessment. I understand that if I request and/or require long term treatment or a level of care beyond CAPS scope of practice, a referral to another agency (on or off campus) will be provided.

I understand that, once my mental health professional and I have decided on a course of treatment, regular attendance and active participation is expected for the duration of my treatment. I understand that if I do not provide at least 24 hours notice when I am unable to attend a scheduled appointment, a $15 fee will automatically be charged to my student account. I understand that if I do not attend 2 sessions without canceling within 24 hours before the appointment, I may be required to consult with my therapist about treatment progress before making another appointment.

I understand that I may contact CAPS in person, via phone or e-mail. I understand that e-mail and cell phones are not a confidential way of communicating. I understand that I may call CAPS 24 hours a day, 7 days a week. I understand that my therapist may not be immediately available and that I will be allowed to either leave a message (i.e., if it is not an emergency) or request to speak to a mental health professional who is immediately available (in a crisis situation).

I understand that I can contact the following resources in an after-hours emergency: CAPS Crisis Line (24/7): 805-756-2511 University Police: 805-756-2281 San Luis Obispo County HOTLINE (24 hour crisis line): 800-783-0607 San Luis Obispo County Mental Health: 805-781-4700 Crisis TEXT Line: Text HELLO to 741741

I understand that CAPS maintains secure electronic client records which include demographic information about me, treatment goals, therapy progress, and any correspondence. I understand that extensive safeguards exist to protect the security of my mental health records and only professional staff who are involved in my treatment have access to these records, including Psychiatry when applicable. I understand that my therapist may share information with a Health Services provider or confidential Safer Advocate if necessary for the coordination of my treatment. If I receive care from a Counseling Services provider in Health Services, I understand that my therapist will give follow up information to the referring Health Services provider.

Except for coordination of my treatment, I understand that all information shared with the mental health professionals at CAPS is confidential and no information will be released without my written consent.

Additionally, I understand that there are specific legal exceptions to confidentiality, which include:

1. When there is reasonable risk of danger to myself or to another person, group of people, or property, the mental health professional is required by law to take reasonable steps to prevent such danger; a. This could include, but is not limited to, members of the campus Students of Concern Team;

2. When there is reasonable suspicion that a child (i.e., person under age 18), elder (i.e., person over age 65), or dependent adult (i.e., person over age 18 who is in the custodial care of someone else) is being abused or is at risk of abuse, the mental health professional is required by law to take reasonable steps to protect the person and to inform the proper authorities;

3. If I am under the age of 16 and was the victim of a crime;

4. If I have engaged in preparing, selling, accessing, streaming, downloading, viewing, and/or distributing material of a minor (i.e., person under age 18) engaged in “obscene” acts, including modeling the act or posing for a video, painting, or drawing of an obscene act, including “sexting;”

5. When a valid legal request is made for my mental health records.

I understand that as a client of CAPS, I have the ability to access some records related to my care via the Health & CAPS portal. I understand that these records will be directly and immediately available through the portal and that anyone who has access to my portal will be able to see these records. I understand that I may protect my privacy by keeping portal credentials secure and confidential. If I have provided access to my portal to others, I understand that I may consider changing my sign-on credentials to protect my privacy.

I understand that if I need additional documentation that is not provided through the portal, I may complete a request for Release of Information.

I understand that while counseling and psychological assessment may provide significant benefits, they may also pose risks. These risks include, but are not limited to, uncomfortable thoughts, feelings, and/or memories.

I understand that there are a variety of treatment alternatives for any given issue and there is the possibility that the services provided will not lead to the desired outcome. I understand that active participation and honesty are essential to effective treatment. I understand that I may terminate services at any time but that premature termination may result in my treatment goals remaining unmet.  I understand that if I am uncomfortable with my therapist, or my therapist is not available for an extended period of time, I can request another mental health professional at any time by talking to my therapist, the front desk staff, or the Director.

I understand that if I have any questions regarding this consent form or the services offered at CAPS, I may discuss them with my therapist, their supervisor, or the Director. I have read and understand the information above. I consent to participate in the assessment and/or treatment offered to me by CAPS. I understand that I may stop treatment at any time.