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NORTH CAROLINA AGRICULTURAL AND TECHNICAL STATE UNIVERSITY COUNSELING SERVICES DIVISION OF STUDENT AFFAIRS MURPHY HALL SUITE 109 1601 EAST MARKET STREET GREENSBORO NC 27411 336 334-7727 WWW.NCAT. EDU PHONE FAX WEB Internship/Practicum/Shadow Graduate Student Confidentiality Form All counseling involves the sharing of sensitive personal and private information by clients with their counselors. NORTH CAROLINA AGRICULTURAL AND TECHNICAL STATE UNIVERSITY COUNSELING SERVICES DIVISION OF STUDENT AFFAIRS MURPHY HALL SUITE 109 1601 EAST MARKET STREET GREENSBORO NC 27411 336 334-7727 WWW*NCAT. EDU PHONE FAX WEB Internship/Practicum/Shadow Graduate Student Confidentiality Form All counseling involves the sharing of sensitive personal and private information by clients with their counselors. Recognizing this several federal and state laws as well as a code of professional ethics protect the confidentiality of information shared in counseling. --------------------------------------------------------------------------------------------------------- As a Practicum Student at North Carolina A T State University Counseling Services I understand and agree I will adhere to all the policies and procedures of North Carolina A T State University and Counseling Services. I will not search or read the contents of other client files nor will I discuss the students with whom I have contact with anyone other than the Counseling Services staff* I may not use any names or other identifying information when documenting or discussing my training experience for class. I will follow the supervision and direction of the Counselor to whom I have been assigned* I understand the failure to adhere to the aforementioned terms will result in my being dismissed from the Internships Practicum or Shadow experience. A copy will be provided for you and one will be retained in your file. Print Name Signature Date Email Training Coordinator EXPLORE DISCOVER BECOME Revised 09/12/2012 V. EDU PHONE FAX WEB Internship/Practicum/Shadow Graduate Student Confidentiality Form All counseling involves the sharing of sensitive personal and private information by clients with their counselors. Recognizing this several federal and state laws as well as a code of professional ethics protect the confidentiality of information shared in counseling. Recognizing this several federal and state laws as well as a code of professional ethics protect the confidentiality of information shared in counseling. --------------------------------------------------------------------------------------------------------- As a Practicum Student at North Carolina A T State University Counseling Services I understand and agree I will adhere to all the policies and procedures of North Carolina A T State University and Counseling Services. --------------------------------------------------------------------------------------------------------- As a Practicum Student at North Carolina A T State University Counseling Services I understand and agree I will adhere to all the policies and procedures of North Carolina A T State University and Counseling Services. I will not search or read the contents of other client files nor will I discuss the students with whom I have contact with anyone other than the Counseling Services staff* I may not use any names or other identifying information when documenting or discussing my training experience for class.

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