Academic Counseling Consent Form

Student Name Student ID Date of Birth

Purpose of Counseling

Consent

I acknowledge that I have been informed about the academic counseling services provided. I understand the purpose, process, and limits of confidentiality surrounding my participation.

I agree and give my consent for academic counseling.

Confidentiality

Information shared during academic counseling sessions will be kept confidential except when disclosure is required by law, or when there is a risk of harm to self or others.

Student Signature

Date

Parent/Guardian Signature (if under 18)

Date

Counselor Name Counselor Signature

Date