BEHAVIORAL HEALTH
Service Agreement between CUSOM Behavioral Health and Client
Welcome to CUSOM Behavioral Health. This document (the Service Agreement) contains important information
about CUSOM Behavioral Health’s professional services and business policies. It is very important that you read it
carefully. We can discuss any questions you have about the procedures, and you may revoke this Agreement in writing
at any time. When you sign this document, it also will represent an agreement between us.
SERVICES
CUSOM Behavioral Health provides supportive, individual, couple, family, and group (offered if students are
interested) counseling free of charge to full-time medical, graduate, and health profession students who are
enrolled currently in for-credit courses at CUSOM and CU. Full-time status is achieved by a student taking 12 or more
credit hours per semester. Students can be seen while the courses in which they are enrolled are in session, and
typically are not seen while classes are not in session or during times when not enrolled in any ongoing classes.
Exceptions may be made for ongoing clients, at the discretion of the Director of CUSOM Behavioral Health. CU
faculty/staff are not eligible for services, but can receive consultation.
Counseling is provided by Dan Marlowe, PhD, LMFT (a Licensed Marriage and Family Therapist). Services are
designed to assist clients with their concerns and enhance their ability to be more effective and successful in their
academic and personal lives. Counseling is seen as another form of learning where individuals are able to learn more
effective means of resolving concerns and developing strategies for achieving their goals. Dr. Marlowe provides
counseling for issues such as: anxiety, depression, loneliness, stress management, time management, relationship
concerns, grief and loss, family stress, homesickness, adjustment to college, developmental issues, as well as personal
growth and development.
Dr. Marlowe provides clients with short-term psychotherapy with many clients finding that their issues are resolved
in 4 – 6 sessions. He does not provide counseling for issues or concerns for which he does not have specific
training/licensing and experience. Concerns that are beyond the scope of care provided by CUSOM Behavioral Health
and/or that involve more intensive, specialized care, or hospitalization will be referred to other mental health providers
in the community (at the student’s expense). This includes, but is not limited to, eating disorders, court-ordered
treatment, psychological testing/assessment, etc. Students requesting and/or requiring those services will be referred
out to local providers (at their expense).
I have read and understand CUSOM Behavioral Health’s policy on services it provides. (Initials) __________
APPOINTMENT ATTENDANCE
Depending on availability of appointments, counseling appointments can be limited (scheduled infrequently).
Consistent attendance at therapy sessions is important to the progress you will make. Although we recognize that not
every scheduling conflict can be anticipated, if for any reason you find that you are unable to keep an appointment,
please call the Student Health Center at least 24 hours prior to your appointment. If you decide to discontinue services,
we would like to discuss this with you in session. Please be aware that if you do not keep scheduled appointments and
have not been seen within 3 months, your file will be considered inactive and services to you will be considered
completed. If you subsequently wish to reconnect with Dr. Marlowe, please contact the Student Health Center.
I have read and understand CUSOM Behavioral Health’s policy on appointment attendance.
(Initials) __________
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SESSIONS
Your first session with Dr. Marlowe is considered the intake, where you and he will discuss why you requested
services and work together to decide if CUSOM Behavioral Health is the best resource to meet your treatment goals.
You will work together to set goals for what you want to gain out of coming to counseling, acknowledging that such
goals may need to be renegotiated as you proceed. A student is considered a client of CUSOM Behavioral Health only
after he/she has attended an initial (intake) appointment. Counseling sessions usually last about 45 minutes and most
times are scheduled every 1-2 weeks. Depending on the service you receive, your specific needs, and demand for
services by other students, sessions may vary in duration and frequency.
I have read and understand CUSOM Behavioral Health’s policy on sessions.
(Initials) __________
COUNSELING
There are many different methods a therapist may use to deal with the problems that you hope to address. He/she can
assist you in clarifying goals & finding solutions to problems through careful listening, guiding self-exploration, and
suggesting new perspectives for consideration. Sessions will focus on: self-awareness, choice, problem-solving,
setting goals for the present and future, responsibility, meaning of life, your strengths and limitations, self-concept,
acceptance, and change. Dr. Marlowe will challenge you in a caring and empathetic manner to look at yourself and
seek alternative options and strategies for handling life. Efforts to change self-perception, emotions, and behaviors
require work both in session and out of session. Some change will occur quickly and easily, but more often, change
requires slow, deliberate, and repeated efforts. Outside of session, there may be homework assignments such as
journal writing, reading, or other methods of self-discovery and expression. Dr. Marlowe will need your collaboration
as you both identify issues that will be worked on in session, acknowledging that some issues may need other
resources (i.e., physician, other campus services, support groups, Alcoholics Anonymous).
You should be aware that while counseling interventions offer potential benefits, they also present possible risks. You
may experience uncomfortable feelings like sadness, guilt, anxiety, anger/frustration, loneliness, and helplessness:
 because therapy often involves discussing unpleasant aspects of your life;
 during/from interpersonal interactions with other people as you change your behavior;
 until you adjust to the changes you’re making and they become a routine part of your life (a result of your
personal growth).
Nevertheless, therapy often leads to better relationships, solutions to specific problems, and significant reductions in
feelings of distress.
WHAT ARE MY RESPONSIBILITIES AS A CLIENT OF CUSOM BEHAVIORAL HEALTH?
1. You are the expert regarding what you are experiencing – you know what has (and hasn’t) worked for you in the
past and what you are (and aren’t) willing to attempt in counseling. You’ll need to communicate these observations
to Dr. Marlowe in order for the two of you to find effective ways of dealing with your concerns.
2. If you agree to attempt an intervention or homework assignment between sessions, follow through with it (the
purpose of such assignments is to increase self-awareness). If you are unsure or uneasy about an assignment,
communicate this to Dr. Marlowe so that the two of you may make an adjustment or try something which feels
more achievable at that time.
INFORMATION ABOUT CUSOM BEHAVIORAL HEALTH STAFF (Professional Disclosure Statements)
The purpose of these Statements is to inform you of staff’s professional credentials, and experience.
Dan Marlowe, PhD, Licensed Marriage & Family Therapist (LMFT)
Dan Marlowe, PhD, LMFT, is the Director of Behavioral Health for Campbell University School of Osteopathic
Medicine and serves as the behavioral health professional for medical, health professional, and graduate students. Dr.
Marlowe received both his Doctorate of Philosophy in Medical Family Therapy and Master of Science in Marriage and
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Family Therapy from East Carolina University in Greenville, NC. He has worked clinically in many different
behavioral health and medical settings including but not limited to: Duke University Medical Center (Durham, NC),
Duke/SRHAEC Family Medicine Center (Fayetteville, NC), Vidant Medical Center (Greenville, NC), James D.
Bernstein Community Health Center (Greenville, NC), and Cherry Hospital (Goldsboro, NC). In all of these settings,
Dr. Marlowe provided clinical services to patients dealing with mental health and substance abuse issues, as well as
worked alongside physicians to help manage patients with complex medical diagnoses.
Dr. Marlowe has worked with clients of all ages (5yrs-85yrs), religious affiliations (Christian, Jewish, Islam, Hindu,
etc.), racial and ethnic backgrounds, and socio-economic statues (SESs). His clinical experience is diverse ranging
from mental health (depression, anxiety, PTSD, bi-polar disorder, etc.) and substance abuse issues, to behavioral
management of medical issues (e.g., diabetes, smoking cessation, weight loss, pain management), to helping couples
and families overcome conflict in their relationships. Dr. Marlowe is also trained in clinical hypnosis, which he uses
regularly for individuals suffering from chronic pain, anxiety and/or phobias, as well as other mental health and
medical related issues.
CHANGING COUNSELORS
Although it is not possible to guarantee outcomes, CUSOM Behavioral Health is committed to providing you quality
services. If you are dissatisfied with any aspect of the service provided, you are urged strongly to speak with Dr.
Marlowe about this.
You also have the right to request a change in therapist, and students are encouraged to discuss their request with Dr.
Marlowe. This is intended to provide an opportunity for you and he to gain a better understanding of the issues
involved, to resolve misunderstandings, and hopefully, to proceed with counseling.
Alternatives to Counseling Services If you no longer wish to receive services from Dr. Marlowe but still wish to
receive counseling; he will help locate three alternative providers of psychological and counseling services in the
community. He will assist you by providing information on these alternatives if you wish, and/or if he believes
alternative services will best meet your needs. **THERE IS NO PUNATIVE ACTION TAKEN FOR
DISCONTUING VOLUNTARY COUNSELING SERVICES**
I have read and understand CUSOM Behavioral Health’s policy on changing counselors. (Initials) __________
E-MAIL and OTHER TECHNOLOGY
Dr. Marlowe does not use email to initiate therapeutic conversations, as e-mail is not considered confidential, and your
privacy is his utmost concern. There is a separate form on which you can consent for communication with you via
email regarding appointment scheduling only (you will be reminded of appointments through email instead of phone
call). Information about your treatment issues or concerns will not be in these emails, however, if you choose to
include information about your own treatment issues/concerns in email communication, please understand that
information may not be restricted to the email sender and receiver (as Dr. Marlowe cannot guarantee confidentiality of these
emails). Please give up to 12 hours for a response to any email (this is important to remember in case of an emergency
situation).
Dr. Marlowe does not engage in electronic social networking (such as Facebook, MySpace, Twitter, LinkedIn) with
clients or former clients of CUSOM Behavioral Health.
I have read and understand CUSOM Behavioral Health’s policy on use of e-mail and other technology.
(Initials) __________
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CONTACT INFORMATION & EMERGENCIES
CUSOM Behavioral Health’s hours of operation are as follows: Monday–Friday (1:00 p.m. - 4:30 p.m).
On Mondays and Wednesdays clients are seen in the Student Health Center (129 TT Lainer St.), and
on Tuesdays, Thursdays, and Fridays clients are seen in the Counseling Services Center (Avrette
House- 60 Pope St.).
To schedule an appointment, please contact the Student Health Center at (910) 814-5720 during normal business
hours.
EMERGENCIES/CRISES
CUSOM Behavioral Health provides crisis intervention during the Counseling Services Center hours of operation
[Monday–Thursday (8:30 a.m. - 4:30 p.m.), and Friday (8:30 a.m. - 12:00 p.m.)]. If you are experiencing a crisis, call
Counseling Services at 910-814-5709 or go to their office (Avrette House- 60 Pope St.) and MAKE IT CLEAR
THAT YOU ARE IN CRISIS AND DR. MARLOWE’S CLIENT. Every effort will be made by Dr. Marlowe to
respond as soon as possible. Students may also call Campbell’s free, confidential Counseling Helpline (866-428-3591).
If you are experiencing suicidal thoughts/actions or have a plan to harm yourself, from campus dial x1911 for
Campus Safety immediately or from elsewhere, dial 911 or present to the nearest hospital immediately for assistance.
If you are experiencing another type of psychological emergency (emotional crisis) after office hours, please contact
Campus Safety (x1911), Residence Life Staff, and/or contact the Counseling Helpline (866-428-3591). If you reside
off of campus, please call 911 for emergency situations.
If we will be unavailable for an extended time, we will provide you with the names of mental health community
resources. If you are unable to reach Dr. Marlowe, Student Health, or Counseling Center staff and feel that you
cannot wait for us to return your call, contact your family physician or the nearest emergency room and ask for the
psychologist or psychiatrist on call.
Attached to this Service Agreement is an information sheet for your use – it identifies guidelines for responding to an
emergency and phone numbers for Crisis Lines and other emergency personnel.
I have read and understand CUSOM Behavioral Health’s policies about contacting their office and what to do
in the event of a crisis or emergency situation; I received an information sheet.
(Initials) __________
LIMITS ON CONFIDENTIALITY
CUSOM Behavioral Health subscribes to the Ethical Standards of Dr. Marlowe’s mental health licensure organization
(i.e., American Association of Marriage and Family Therapy), as well as the professional laws of the State of North
Carolina. Adherence to ethical standards and state law ensures the confidentiality of all voluntary counseling and
assessment services. Information that you share with CUSOM Behavioral Health and Dr. Marlowe’s record of his
work with you is confidential. These records belong to CUSOM Behavioral Health and are NOT part of your
academic records.
This means that the information will not be shared with your family, University Personnel, students, or others
unless:
(1) you give prior written authorization.
(2) court-ordered disclosures.
(3) when the North Carolina law requires, as in the case of the presence of child or elderly abuse, neglect, or
exploitation [i.e., 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 sexually and/or physically
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abused or is at risk of such abuse], then the Counselor is required to inform the proper authorities, which is the local
Department of Social Services.
(4) if, in Dr. Marlowe’s opinion, you are a clear danger to self or others (i.e., when there is risk of imminent danger to
you or to another readily identifiable person or group of people). In such cases, Dr. Marlowe acts on your behalf (behalf
of the client) consistent with safety needs and State laws. In the event a student is determined to be a danger to self
and/or others, information will be shared with appropriate and necessary campus personnel [i.e., Student Life
Personnel (including Vice President for Student Life, Dr. Dennis Bazemore, and/or Dean of Students, Dr. Sherry Haehl), Campus
Safety, Campbell University Behavioral Intervention Team] . If Dr. Marlowe believes that a student presents an imminent
danger to his/her health or safety, he may be obligated to seek hospitalization for him/her or to contact family
members or others who can help provide protection. In an effort to keep safe the student and/or university
community, other appropriate and necessary campus personnel will be contacted, and this information will be shared
with them [i.e., Student Life Personnel (including Vice President for Student Life, Dr. Dennis Bazemore, and/or Dean of
Students, Dr. Sherry Haehl), Campus Safety, Campbell University Behavioral Intervention Team] .
You may want Dr. Marlowe to speak with a professor, family member, or someone else. This is done gladly with your
written consent. Please note that you may be called by name in waiting and service areas within the Student Health
Center and/or Counseling Services. Please note if Dr. Marlowe sees you on campus or in the community, he will not
initiate contact as to do so would compromise your confidentiality. If you choose to initiate contact with him (or not),
he will respect your choice.
In most situations, CUSOM Behavioral Health only can release information about your treatment to others if you sign
a written authorization or consent form that meets certain legal requirements. There are other situations that require
you provide only written, advanced consent. Your signature on this Agreement provides advanced consent for
those activities, as follows:


Dr. Marlowe may find it helpful to consult with other health and mental health professionals about a case. As mentioned
above, no student name or identifying information is released so as to avoid revealing the identity of the client. The other
professionals also are bound legally to keep the information confidential. If you do not object, we will not tell you about these
consultations unless we feel that it is important to our work together.
If we believe that a student presents an imminent danger to his/her health or safety, we may be obligated to seek
hospitalization for him/her or to contact family members or others who can help provide protection. In an effort to
keep safe the student and/or university community, other appropriate and necessary campus personnel will be
contacted, and this information will be shared (i.e., Student Life Personnel, Campus Safety, CU Behavioral Intervention
Team).
Some situations where CUSOM Behavioral Health is permitted/required to disclose information without your consent
or authorization:


If you are involved in a court proceeding and a request is made for information concerning the professional services that we
provided you, such information is protected by the therapist-client privilege law. We cannot provide any information without
your written authorization or a court order. If you are involved in or contemplating litigation, you should consult with your
attorney to determine whether a court would be likely to order us to disclose information.
If a client files a complaint or lawsuit, we may disclose relevant information regarding that client in order to defend ourselves.
While this written summary about confidentiality should prove helpful in informing you about potential problems, it is important
that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite
complex, and we are not attorneys. In situations where specific advice is required, formal legal advice may be needed.
I have read and understand CUSOM Behavioral Health’s policy on confidentiality. (Initials) __________
PROFESSIONAL RECORDS
You should be aware that CUSOM Behavioral Health keeps your Clinical Record is kept in a HIPPA compliant
electronic health record system separate from your academic records. Your Clinical Record includes information about
your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your
diagnosis, the goals that we set for treatment, your progress towards those goals, your medical/social/treatment history,
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current alcohol and drug use, history of substance abuse, your attendance record, and any correspondence that has been
sent to anyone (i.e., letters). Except in unusual circumstances that involve danger to yourself and/or others or in cases
where the record makes reference to another person (unless such other person is a health care provider) and we believe
that access is reasonably likely to cause substantial harm to such other person, you may request, in writing, a copy of
your Clinical Record through the Student Health Center. Because these are professional records, they can be
misinterpreted and/or upsetting to untrained readers. For this reason, they will be reviewed in the presence of a staff
mental health professional or we will forward them to another mental health professional so you can discuss the
contents.
I have read and understand CUSOM Behavioral Health’s policy on professional records. (Initials) __________
MAINTENANCE OF RECORDS
Any information disclosed during your contacts with CUSOM Behavioral Health, or records maintained in written
and/or electronic form, are kept strictly confidential as required by State and Federal law, and by applicable ethical
standards. All computer and paper records are stored with strict attention to security as well. Per state law, complete
records are maintained for seven (7) years following the last activity on the file and then are destroyed. All records are
stored and retrieved according to ethical standards; at no time is the confidentiality of records compromised. Records
containing information about your visits are stored in a HIPPA compliant EHR system, and said files are accessible
only by authorized personnel of CUSOM Behavioral/Student Health Services. If you have question(s) concerning your
records, please ask the Director of CUSOM Behavioral Health.
CUSOM Behavioral Health stores client files electronically on a server that is in a physically secure facility, and such
files are only accessible to authorized personnel of Behavioral/Student Health Services, or to Information Technology
(IT) administrators (not students) to maintain that server. The data is encrypted and password protected to ensure the
utmost security and confidentiality.
Your written permission is required before any information about your contacts with CUSOM Behavioral Health is
released to anyone outside of CUSOM Behavioral Health.
I have read and understand CUSOM Behavioral Health’s policy on maintenance of records.
(Initials) __________
COMPLAINTS
If you have complaints about our services, please feel free to discuss those with the Director of CUSOM Behavioral
Health, Dr. Dan Marlowe, and your concerns will be documented and taken into consideration. Complaints about
services can also be forwarded to the following Student Life personnel: Dean of Students, Dr. Sherry Haehl (910-8145582), or Vice President for Student Life, Dr. Dennis Bazemore (910-893-1540) – [their offices are located on the 2nd
floor of the Wallace Student Center].
If you have questions about this Service Agreement, disagree with a decision we make about access to your records,
believe that your privacy rights have been violated and wish to file a complaint with our office or have other concerns
about your privacy rights, you may contact Dr. Dan Marlowe, Director of Behavioral Health Services, Campbell
University School of Osteopathic Medicine, Lillington, NC 27546, (910) 814-4959. You may also send a written
complaint to the Secretary of the U.S. Department of Health and Human Services. Dr. Marlowe can provide you with
the appropriate address upon request. You have specific rights under the Privacy Rule. Behavioral Health Services will
not retaliate against you for exercising your right to file a complaint.
Your signature below indicates that you have read and understand the information in this document, and agree to abide
by its terms during our professional relationship.
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_____________________________________________________
Student’s Printed Name & Signature of Student
_____________________________________________________
Dan Marlowe, PhD, LMFT
____________________________
Date
____________________________
Date
_______________________________________________________________________________________
If Service Agreement is signed by a personal representative of the student, a description of such representative’s authority to act
for the student must be provided. Please discuss any questions or concerns about the above information with the Director of
CUSOM Behavioral Health.
Copies of this document are available upon request.
CUSOM Behavioral Health Services Agreement
Revised 08/07/2013
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