Counselling and Career
Centre
100 College Blvd
Box 5005
Red Deer, Alberta
CANADA T4N 5H5
Telephone: 403.343.4064
Fax:
403.342.3424
Email: [email protected]
CONSENT TO OBSERVE AND
RECORD COUNSELLING
SESSION
COUNSELLING AND CAREER CENTRE
The personal information that you provide on this form is being collected under the authority of the Post-Secondary Learning Act and the
Freedom of Information and Protection of Privacy Act of Alberta. The personal information will be protected in compliance with the
provisions of the Freedom of Information and Protection of Privacy Act of Alberta. The information will be retained by the Counselling and
Career Centre in accordance with approved Information Management guidelines, after which it will be destroyed in a secure manner. If
you have questions regarding the collection and use of this personal information, please contact the Chair of Personal and Career
Counselling, Counselling and Career Centre, Red Deer College, 100 College Blvd, Box 5005, Red Deer, AB T4N 5H5. Telephone:
403.343.4064.
Supervisory observation or a videotaped review of counselling sessions is used to enhance therapy
effectiveness and promote professional skill development of the Counsellors at Red Deer College.
The benefit to you includes enhanced Counsellor effectiveness through the generation of ideas/options that
result from supervisor/peer input. You will also gain the benefit of additional consultation regarding your issues
or concerns. You can be assured that the Counsellors and/or Chairperson/Supervisor of the Counselling and
Career Centre will maintain the strictest confidentiality.
If you agree to have your counselling session observed and/or recorded, please sign the following consent
acknowledgement.
ACKNOWLEDGEMENT
I have read and understand the information presented in this agreement and give permission for my Counsellor
to be observed and/or for the counselling session to be recorded for the stated purposes. I understand that
access to my counselling services is not related to my agreement for this observation or recording and that I
can withdraw my consent at any time. If the sessions are recorded, I understand that all recorded material will
be stored confidentially and erased immediately upon review.
Please check
the appropriate box.
Counselling session recording
Supervisory observation
This authorization will be valid only during the current academic year.
CLIENT’S SIGNATURE
COUNSELLOR’S SIGNATURE
DATE
WITHDRAWAL OF CONSENT
CLIENT’S SIGNATURE
WITNESS
DATE
08/10