UNIVERSITY OF EDUCATION- WINNEBA

FACULITY OF EDUCATIONAL STUDIES

DEPARTMENT OF COUNSELLING PSYCHOLOGY

PROFESSIONAL DISCLOUSURE AND INFORM CONSENT FORM

I am a student counselor at the University of Education-Winneba and am in the department of

counselling psychology. I am under training to work with clients with personality and anxiety
disorders. Before beginning therapy, we will go over your concerns and try to resolve them or
gain your understanding. We will be having 12 sessions in which we will meet once every
week. We will sit and talk together in order for me to get to know you more. A successful
therapy is the one in which I (counsellor) and you (client) work collaboratively.

I want to assure you that everything we talk about here is strictly confidential; any notes I
take, audio recordings, or video readings during sessions will be kept confidential and secure
at all times, and I will not disclose them to anyone without your prior written consent. With
exception to certain limitation by law such as; Abuse of a kid, disabled person, old person,
other people, or oneself is an exception to some legal limitations. Ghana's Criminal Act 29:
sexual offenses: rape, defilement, which may include the transmission of sexually transmitted
illness, and this will compel me to reveal our conversation. If you have any concerns about
confidentiality, please inquire and we will address them.

CLIENT’S CONSENT

o I have read the consents and fully understand contents indicated therein.
o I understand the confidentiality that is required by the therapist to perform, as well as
o I understand my therapist’s responsibilities as well as my rights, limitations, and
responsibilities as a client.
o I am aware that I can end my therapy when I feel threaten, I need to inform my
therapist first.
o I am above legal age and hereby voluntarily give my informed consent to this
agreement with full knowledge of my rights and obligations
Name
First name Middle Name Last Name

Signature

Date
mm/dd/yyyy

Student Counselor consent

o As a student counselor, I have explained to the client the relevant
information contained in this informed consent. I have given him/her
opportunities to ask questions as we as I have answered the questions to
his satisfaction.

Counselor
Prefix First name Middle name Last name

Signature