Counseling Services Guidelines Counseling and Psychological Services (CAPS) California State University, Long Beach (562)
|
|
|
- Ethelbert Tucker
- 8 years ago
- Views:
Transcription
1 Counseling Services Guidelines Counseling and Psychological Services (CAPS) California State University, Long Beach (562) In order to provide quality counseling services to a greater number of students, Counseling and Psychological Services has established the following guidelines. Feel free to discuss these guidelines with your counselor. Arrive on time and cancel or reschedule early. Please help us provide the best service possible by arriving on time for appointments and by canceling or rescheduling appointments early when an appointment must be missed. Failure to cancel or reschedule an appointment early results in another student not receiving a critically needed appointment. A minimum of 24 hour notice is required for rescheduling, or cancellation of an appointment. Since the scheduling of an appointment involves the reservation of time set aside for a specific client, a minimum of 24 hours notice is required for rescheduling, or cancellation of an appointment. Failure to reschedule or cancel an appointment 24 hours in advance results in the missed session being considered a utilized appointment hour. No-Show Appointments count. When a client does not appear for a scheduled appointment, it is considered a utilized appointment hour. A client who does not appear for their first scheduled appointment, and/or has a pattern of missed appointments, jeopardizes his/her ability to receive services at CAPS.
2
3
4 C A L I F O R N I A S T A T E U N I V E R S I T Y, L O N G B E A C H COUNSELING AND PSYCHOLOGICAL SERVICES CSULB CAPS PARTICIPATION IN CCMH RESEARCH CSULB s Counseling and Psychological Services (CAPS) participates in a national research project designed to improve our services and expand the knowledge about college student mental health. We participate by contributing anonymous, numeric data provided by those who use our services (and are over 18 years old) to a database managed by researchers at Penn State University. Data is stripped of all personally identifying information and then combined with anonymous, numeric data from other colleges nationwide for statistical analysis. Because data cannot be linked to specific individuals, there are virtually no risks contributing to data. With your permission, we would like to contribute anonymous, numeric data from the questionnaires you just completed. Your decision is voluntary and will not affect the services you receive. If you have questions or concerns, you may contact the clinical coordinator, Dr. Ferdinand Arcinue at ferdinand.arcinue@csulb.edu or Counseling and Psychological Services (CAPS) Data Contribution to the Center for Collegiate Mental Health (CCMH) You are asked to participate in a research study conducted by Ferdinand Arcinue, Ph.D. from Counseling and Psychological Services (CAPS) at California State University, Long Beach. You were selected as a possible participant in this study because you have sought services at CAPS. Purpose of the Study CSULB s Counseling and Psychological Services (CAPS) participates in a national research project, lead by the Center for Collegiate Mental Health (CCMH) designed to improve our services and expand the knowledge about college student mental health. Over 160 other university counseling centers are participating in this study. Procedures If you volunteer to participate in this study, you will do the following things: Fill out CAPS intake forms including the Standardized Data Set (SDS) and the Counseling Center Assessment of Psychological Symptoms (CCAPS). If you consent to participate in this research, your information will be deindentified and contributed anonymously to the study. CAPS uses the Counseling Center Assessment of Psychological Symptoms (CCAPS) to monitor your progress in counseling. Therfore, we ask all clients to fill out this brief questionnaire at every third meeting. The questionnaire takes 2-3 minutes on average to complete. If you consent to participate in this research, your information will be deindentified and contributed anonymously to the study. Potential Risks and Discomforts The SDS and CCAPS forms are collected as part of our routine clinical intake process. Due to the nature and content of clinical psychological practice, the questions may pose some discomfort. Regarding confidentiality, this project contributes anonymous and de-identified data to CCMH and should pose no risk to participants. Potential Benefits to Subjects and/or to Society Clients' individual psychological treatment may be enhanced by providing nationally standardized information to counseling center staff about clients' demographic characteristics and problems for which they are seeking psychological care. Contributing data to CCMH will assist in the vision of providing accurate, national data regarding the scope and severity of presenting concerns among college students and student usage of campus mental health systems. In 1250 BELLFLOWER BOULEVARD, BH-226 LONG BEACH, CA / FAX 562/
5 addition, contributing data will assist with making improvements to research, treatment, and evaluation of college student mental health. Payment for Participation There is no payment for participation in this study. Emergency Care and Compensation for Injury Since the SDS and CCAPS are part of our routine intake paperwork, any discomfort related to the questions can be addressed by your intake counselor. If you are uncomfortable with participating in the national study, you may decline consent. In addition, you may speak to the clinical coordinator, Dr. Ferdinand Arcinue, if you have any concerns about participation. Confidentiality All identifying information will be removed and each participant will be assigned a new unique ID number which cannot be reverse engineered, data will be encrypted for secure transmission, and it will not be possible to trace transferred data back to a specific client. Participation and Withdrawal You can choose whether to be in this study or not. If you volunteer to be in this study, you may withdraw at any time without consequences of any kind. Participation or non-participation will not affect your services at CAPS or any other personal consideration or right you usually expect. You may also refuse to answer any questions you don't want to answer and still remain in the study. The investigator may withdraw you from this research if circumstances arise which in the opinion of the researcher warrant doing so. Identification of Investigators If you have any questions or concerns about the research, please feel free to contact CAPS clinical coordinator, Dr. Ferdinand Arcinue, at Rights of Research Subjects You may withdraw your consent at any time and discontinue participation without penalty. You are not waiving any legal claims, rights or remedies because of your participation in this research study. If you have questions regarding your rights as a research subject, contact the Office of University Research, CSU Long Beach, 1250 Bellflower Blvd., Long Beach, CA 90840; Telephone: (562) or to research@csulb.edu. Approved from July 6, 2013 to July 5, 2014 by the CSULB IRB BELLFLOWER BOULEVARD, BH-226 LONG BEACH, CA / FAX 562/
GUIDELINGS FOR PSYCHOLOGY STUDENT RESEARCH PARTICIPATION
GUIDELINGS FOR PSYCHOLOGY STUDENT RESEARCH PARTICIPATION George Mason University Psychology Department Table of Contents I. Introduction..1 II. Researchers Responsibilities..2 III. Course Instructors Responsibilities...7
Miami University: Human Subjects Research General Research Application Guidance
Miami University: Human Subjects Research General Research Application Guidance Use the accompanying Word template for completing the research description. You must provide sufficient information regarding
State University of New York at Canton Institutional Review Board. Sample Informed Consent Document
State University of New York at Canton Institutional Review Board Sample Informed Consent Document The following sample informed consent document includes instructions to the person writing the document,
Sincerely yours, Rev. 06.10
Welcome to RehabXperience. Thank you so much for choosing us. We recognize that you have a choice of physical therapy centers and greatly appreciate you for choosing us as your outpatient physical therapy
HIPAA Authorization (Health Information Privacy Rights)
ALBANY MEDICAL CENTER ALBANY, NY 12208 PERMISSION TO TAKE PART IN A HUMAN RESEARCH STUDY AND HIPAA Authorization (Health Information Privacy Rights) Title of research study: Prospective Database Multidisciplinary
Peaceful Path Counseling, LLC Amy Kay, LPC
Revision VII, Effective January 15, 2015 Please Keep This for Your Records INTRODUCTION Welcome to my counseling practice. The decision to pursue counseling is an important one, often filled with questions.
The easiest way to think about subject hours is as credits. 1 subject pool credit granted = 1 subject hour used. 4) How do I get subject hours?
Frequently Asked Questions for Conducting Research Using the Psychology Course Credit Subject Pool 1) Who can use the Psychology Course Credit Subject Pool? Faculty, post-docs, graduate students and honors
Orange Coast College. Veterans Services. You proudly served us. We proudly serve you.
Orange Coast College Veterans Services You proudly served us. We proudly serve you. OCC Student Veterans Program You proudly served us. Now we proudly serve you. Our primary goal is to provide comprehensive
The Michigan State University Institute for Health Policy (IHP) is recruiting a sample of office based primary care providers to be interviewed
The Michigan State University Institute for Health Policy (IHP) is recruiting a sample of office based primary care providers to be interviewed concerning their perceptions of the Meaningful Use of electronic
The Clarity Psychological Group 3915 Cascade Rd. SW Suite 250 Atlanta, GA 30331 P. (404) 699-3170 F. (404) 699-5680
The Clarity Psychological Group 3915 Cascade Rd. SW Suite 250 Atlanta, GA 30331 P. (404) 699-3170 F. (404) 699-5680 Dear Client: It is a pleasure to have you in our practice. We appreciate the opportunity
Pl"OtocolDirector: Iris Schrijver _ IRB Approval Date: _June 20 2006 IRE Expiration Date: June 19, 2007 _ STANFORD SAMPLE CONSENT FORM
Protocol Title: Molecular genetic basis of sensorineural hearing Pl"OtocolDirector: Iris Schrijver IRB Approval Date: June 20 2006 IRE Expiration Date: June 19, 2007 STANFORD SAMPLE CONSENT FORM Please
602%548%8508!(Main!Office)! 623%670%2927!(Direct!Line)! 17505!N.!79 th!avenue,!suite!410! Glendale,!AZ!85308!
602%548%8508(MainOffice) 623%670%2927(DirectLine) 17505N.79 th Avenue,Suite410 Glendale,AZ85308 I want you to be well informed regarding your prospective counselor s credentials and level of experience
Notice of Privacy Practices
SHANNON LERACH, Ph.D. Licensed Clinical Psychologist PSY23705 243 N. Highway 101, Suite 16, Solana Beach, CA 92075 Telephone: (619) 817.5320 Fax: (858) 481.1674 Notice of Privacy Practices This Notice
CLINICAL RESEARCH DATA COLLECTION STUDY Cervical Spine Patients Treated with Cox Technic
CLINICAL RESEARCH DATA COLLECTION STUDY Cervical Spine Patients Treated with Cox Technic Headed by Dr. Jerrilyn Cambron at the National University of Health Sciences Research Department, coinvestigator
July 2007. Executive
July 2007 Executive The BENEFITS Benefits of Working at the CSU This summary of executive perquisites, relocation benefits, and general benefits provides an overview of systemwide benefits generally available
Bert Epstein, Psy.D.
Bert Epstein, Psy.D. 159 Kentucky Street Suite 3 Petaluma, CA 94952 707 242-1989 bert@drbertepstein.com CA License PSY 21404 Office Policies & Agreement for Psychotherapy Services Welcome. Your first visit
Information about the research
Information about the research Health beliefs in OCD participants with OCD information sheet (non-nhs participants version) We would like to invite you to take part in our research study. The study is
This document highlights most of the changes and gives additional information to explain the ramifications of these changes.
October 30, 2007 Overview Major Changes Minor Changes Data Forms When to Update How to Update Warnings Helping you Help Others Overview This is the most significant update to Titanium in years. The challenge
GOALS OF COUNSELING RISKS/BENEFITS OF COUNSELING
1 Welcome to. This document contains important information about my professional services and business policies. Attached is also a summary of information about the Health Insurance Portability and Accountability
RESEARCH PARTICIPANT INFORMED CONSENT AND PRIVACY AUTHORIZATION FORM
If you are using Epic for this study, fax a copy of the signed consent form to 410-367-7382. Patient I.D. Plate RESEARCH PARTICIPANT INFORMED CONSENT AND PRIVACY AUTHORIZATION FORM Protocol Title: Application
INFORMED CONSENT FOR EGG DONORS PRACTITIONER S GUIDE TO USING THE MODEL FORM
INFORMED CONSENT FOR EGG DONORS PRACTITIONER S GUIDE TO USING THE MODEL FORM A. GENERAL GUIDELINES AND COMMENTS Purpose and Use of the Model Form This is a guide for practitioners to using the Model Informed
AGAPE. Therapist Client Services Agreement
Revised 7/1/08 AGAPE Therapist Client Services Agreement AGAPE is a faith-based organization guided by Christian values. As part of its overall mission, AGAPE offers professional counseling and psychological
ADULT REGISTRATION FORM. Last Name First Name Middle Initial. Date of Birth Age Identified Gender. Street Address. City State Zip Code
ADULT REGISTRATION FORM Last Name First Name Middle Initial Date of Birth Age Identified Gender Street Address City State Zip Code Home Phone Cell Phone FINANCIALLY RESPONSIBLE PARTY (If different from
Date Submitted: 7/15/2011. Unit: Counseling and Career Services at Oxford. Contact Person: Joe Moon and Sandra Schein
EMORY UNIVERSITY 2010-2011 Assessment Report for Administrative and Educational Support Units Assessment Period Covered: September 1, 2010-August 31, 2011 Unit: Counseling and Career Services at Oxford
Nova Southeastern University IRB - Consent Form Checklist Version Date: 02/17/2010
Nova Southeastern University IRB - Consent Form Checklist Version Date: 02/17/2010 This form is intended to assist researchers in creating consent and assent forms. Informed consent is one of the primary
Troy Cablevision, Inc. Subscriber Privacy Policy
Troy Cablevision, Inc. Subscriber Privacy Policy Troy Cablevision, Inc. ( Troy Cable ) is committed to protecting and securely maintaining our customers privacy. The following privacy policy applies to
Beth Cerrito, Ph.D. Licensed Clinical Psychologist 1357 Monroe Avenue Phone: (585) 442-9601 Rochester, NY 14618 Fax: (585) 442-9606
Beth Cerrito, Ph.D. Licensed Clinical Psychologist 1357 Monroe Avenue Phone: (585) 442-9601 Rochester, NY 14618 Fax: (585) 442-9606 CONSENT FOR EVALUATION AND TREATMENT Welcome to my practice. This document
InterOffice Memorandum
InterOffice Memorandum TO: FROM: Faculty and graduate students George Hollich Director of Undergraduate Studies DATE: 12 August 2010 SUBJECT: PSY 390 (a.k.a. PSY 39000) for this semester Please be advised
CLIENT QUESTIONNAIRE
Leland E. McHatton, MFT Marriage Family Therapist 1430 East Avenue, Suite 4C 530.566.1212 Chico, California 95926 CLIENT QUESTIONNAIRE Client s Name: Spouse s or Parent s Name: Date of Birth: Date of Birth:
in Nursing Accelerated BSN Program
California State University, Long Beach 1250 N. Bellflower Boulevard Long Beach, CA 90840-0301 Bachelor of Science in Nursing Accelerated BSN Program University Application Deadline is November 30 Application
Sample Consent. Transfusion of Prematures (TOP)
Final: October 8. 2012 Revised: February 8. 2013 Appendix A: Sample Consent ~ Penn Medicine,~. Informed Consent Form and HIPAA Authorization Protocol Title: Short Title: Principal Investigator: Emergency
DUI... INSTANT CRIMINAL RECORD
DUI... INSTANT CRIMINAL RECORD TABLE OF CONTENTS Implied Consent How DUIs Are Handled p. 2 p. 2 I. DUI ADMINISTRATIVE PROCEDURES II. DUI COURT PROCEDURES A. Penalties B. First Offense Election C. IID License
Handbook for Psychology Undergraduate Research Experience (PURE) 2015 Spring Edition. Sona Administrators. Department of Psychology
Handbook for Psychology Undergraduate Research Experience (PURE) 2015 Spring Edition Sona Administrators Department of Psychology Western Illinois University PURE Handbook 2 Introduction Welcome! In general
150 Fountains Blvd Madison, MS 39110 601-898-4947
150 Fountains Blvd Madison, MS 39110 601-898-4947 Welcome to The Center for Hope & Healing! CHH is a ministry of Broadmoor Baptist Church aimed at promoting emotional, relational, and spiritual health
CSU, Long Beach Overview of Available Benefits
CSU, Long Beach Overview of Available Benefits Benefits Services 1250 Bellflower Blvd MS 0124 Brotman Hall-358 Long Beach, CA 90840 (562) 985-2381 benefits@csulb.edu 1 Welcome to CSULB The Benefit Summary
TIVERTON PSYCHOLOGICAL SERVICES 2128 MAIN ROAD TIVERTON, RI 02878 www.tivertonpsych.com Phone: 401-624-9972; Fax: 401-624-1452
TIVERTON PSYCHOLOGICAL SERVICES 2128 MAIN ROAD TIVERTON, RI 02878 www.tivertonpsych.com Phone: 401-624-9972; Fax: 401-624-1452 Dorothy B. Brown, Ph.D. Anne Davidge, Ph.D. Dennis J. Rog, Ed.D. Licensed
Client s Rights and Counselor Responsibilities
Client s Right to Give Informed Consent Client s Rights and Counselor Responsibilities Chapter 5 Psychology 475 Professional Ethics in Addictions Counseling Listen to the audio lecture while viewing these
INDIVIDUALIZED FAMILY SERVICE PLAN
INDIVIDUALIZED FAMILY SERVICE PLAN Introduction [34 CFR 303.20] The Individualized Family Service Plan (IFSP) is the written agreement between the family and the local tiny-k program that documents a plan
Master of Science in Health Care Administration Accelerated Program
Master of Science in Health Care Administration Accelerated Program Thank you for your interest in the Master of Science in Health Care Administration Accelerated Program. Included in this package you
Family Life Resource Center CLIENT CLINICIAN SERVICE AGREEMENT & INFORMED CONSENT
Family Life Resource Center CLIENT CLINICIAN SERVICE AGREEMENT & INFORMED CONSENT Thank you for choosing Family Life Resource Center (FLRC) as your mental health provider. This document contains important
Instructions for Participating in the Psychology Course Credit Subject Pool Summer 2016
Instructions for Participating in the Psychology Course Credit Subject Pool Summer 2016 Below are instructions about participating in the Psychology Department s Course Credit Subject Pool. Please read
Welcome! Enjoy your educational experience at Golden West College and we look forward to helping you through this experience.
Online Orientation Welcome! Welcome to the Golden West College CalWORKs Program. We have dedicated staff and counselors who want to assist you in getting the guidance and resources needed to meet your
Welcome Information. Registration: All patients must complete a patient information form before seeing their provider.
Welcome Information Thank you for choosing our practice to take care of your health care needs! We know that you have a choice in selecting your medical care and we strive to provide you with the best
KUTTEH KE FERTILITY ASSOCIATES OF MEMPHIS, PLLC AND MEMPHIS FERTILITY LABORATORY, INC.
1 of 6 KUTTEH KE FERTILITY ASSOCIATES OF MEMPHIS, PLLC 80 Humphreys Center, Suite 307 Memphis, Tennessee 38120-2363 (901) 747-2229 AND MEMPHIS FERTILITY LABORATORY, INC. IN VITRO FERTILIZATION/EMBRYO TRANSFER
PATIENT INFORMATION Please complete for self or minor child responsible party information below. Street Apt. City State Zip
Name: Address: E-mail: Phone numbers: Lisa Dungate, Psy.D., M.A. Mental Health Counseling PATIENT INFORMATION Please complete for self or minor child responsible party information below DOB: Street Apt.
Dale C. Godby, Ph.D., ABPP, CGP 6330 LBJ Suite 150 Dallas, Texas 75240 972-233-0648
Dale C. Godby, Ph.D., ABPP, CGP 6330 LBJ Suite 150 Dallas, Texas 75240 972-233-0648 Problems in love and work, as well as troubling symptoms like depression and anxiety, often lead people to seek therapy.
CORD BLOOD TRANSPLANTATION STUDY EXPANDED ACCESS PROTOCOL APPENDIX A SAMPLE CONSENT FORM
APPENDIX A SAMPLE CONSENT FORM CORD BLOOD TRANSPLANTATION (COBLT) STUDY SAMPLE CONSENT FORM FOR THE EXPANDED ACCESS PROTOCOL You (your child) are being asked to take part in a clinical research study.
3. Has a disability which has been verified and accepted by the Employment Development Department (EDD), and
NON-INDUSTRIAL DISABILITY INSURANCE (NDI) OVERVIEW WHAT IS NON-INDUSTRIAL DISABILITY INSURANCE (NDI)? NDI is a wage continuation program that provides income for eligible employees who are disabled and
UWM Counseling and Consultation Services Intake Form
UWM Counseling and Consultation Services Intake Form Dear Student, Date Affix Label Here (Office Use Only) Thank you for giving us the opportunity to better serve you. Please help us by taking a few minutes
UNIVERSITY OF NORTH GEORGIA CLINICAL MENTAL HEALTH COUNSELING CLINIC STUDENT HANDBOOK. For COMMUNITY COUNSELING CLINIC HANDBOOK
UNIVERSITY OF NORTH GEORGIA CLINICAL MENTAL HEALTH COUNSELING CLINIC STUDENT HANDBOOK For COMMUNITY COUNSELING CLINIC HANDBOOK If you need this document in another format, please email Shanta Ghimire at
RESEARCH PARTICIPANT INFORMED CONSENT AND PRIVACY AUTHORIZATION FORM
Patient I.D. Plate RESEARCH PARTICIPANT INFORMED CONSENT AND PRIVACY AUTHORIZATION FORM Protocol Title: Application No.: Sponsor: The National Simulation Study: Evaluating Simulated Clinical Experiences
Renee Bellis, PsyD, CSAC Clinical Psychologist & Certified Substance Abuse Counselor 850 West Hind Dr. Suite # 110 Honolulu, HI 96821 P(808) 781-8187
Renee Bellis, PsyD, CSAC Clinical Psychologist & Certified Substance Abuse Counselor 850 West Hind Dr. Suite # 110 Honolulu, HI 96821 P(808) 781-8187 F(808) 748-0778 OUTPATIENT SERVICES CONTRACT This document
Explanation of Services and Informed Consent for Treatment
Explanation of Services and Informed Consent for Treatment The following is offered for your information about services at Mind Spa. If you have further questions, please feel free to bring them up with
Understanding Psychological Assessment and Informed Consent
Understanding Psychological Assessment and Informed Consent You have taken the first step to feel more successful and empowered in your life by choosing to participate in a Psychological Assessment. Thank
CONSENT FORM TEMPLATE FOR HUMAN SUBJECTS PARTICIPATING IN RESEARCH
CONSENT FORM TEMPLATE FOR HUMAN SUBJECTS PARTICIPATING IN RESEARCH SOCIAL SCIENCE, BEHAVIORAL, EDUCATION INSTITUTIONAL REVIEW BOARD (SIRB) Michigan State University Instructions to the Researcher Informed
MEDIATION PROCEDURES FOR RESOLVING BUSINESS-TO-BUSINESS DISPUTES
6465 Wayzata Blvd., Suite 470 Minneapolis, MN 55426 Phone: 800-474-2371 Fax: 952-345-1160 www.adrforum.com MEDIATION PROCEDURES FOR RESOLVING BUSINESS-TO-BUSINESS DISPUTES July 11, 2014 1 FORUM Request
Informed Consent for Counselling at the University of Lethbridge 1
Informed Consent for Counselling at the University of Lethbridge 1 Purpose: For you to understand the process and nature of counselling as well as the associated risks and benefits, in order for you to
Institutional Review Board for the Use of Human Subjects in Research GUIDELINES FOR A PROPOSAL NARRATIVE
Institutional Review Board for the Use of Human Subjects in Research GUIDELINES FOR A PROPOSAL NARRATIVE In your narrative, address each of the topics outlined below. Every application for IRB review must
Missouri Valley College Counseling Center Policy and Procedures
Missouri Valley College Counseling Center Policy and Procedures 500 E College St. Marshall, MO 65340 660-831-4139 660-831-4071 Adopted: August 2012 MVC Counseling Center Policy and Procedure Manual Page
New Venture Christian Fellowship Therapy Introduction to Individual Counseling
New Venture Christian Fellowship Therapy Introduction to Individual Counseling Welcome to counseling. We look forward to meeting with you and getting started. People and their situations are often very
Institutional Review Board
Institutional Review Board Ethical Principles of Informed Consent Informed Consent Guidelines The principle of respect for persons requires that people be given the opportunity to choose what will or will
Information about the research
Information about the research Health beliefs in OCD participants with OCD information sheet (Non-qualitative interview version) We would like to invite you to take part in our research study. The study
HIPAA Compliance Manual
HIPAA Compliance Manual HIPAA Compliance Manual 1 This Manual is provided to assist your efforts to comply with the federal privacy and security rules mandated under HIPAA and HITECH, specifically as said
2.00 THE VOCATIONAL REHABILITATION PROCESS
2.00 THE VOCATIONAL REHABILITATION PROCESS Introduction This chapter describes the procedures involved when an individual is moving through the rehabilitation process from referral to closure. Statuses
Downloadable Forms: Otsego County Chemical Dependencies Clinic. Client Handbook. Revised 04/10
Downloadable Forms: Otsego County Chemical Dependencies Clinic Client Handbook Revised 04/10 OTSEGO CHEMICAL DEPENDENCIES CLINIC 242 Main St, 2 nd Floor Oneonta, New York 13820 Tel. (607) 431-1030 Fax.
Warner Family Counseling
Warner Family Counseling General Policies Insurance: I will file claims on your behalf, provided that I am an in-network contracted provider with your individual plan. Prior to our first meeting contact
MODEL FORM. [Program s SART Name and Number] INFORMED CONSENT FOR EGG DONORS
![MODEL FORM. [Program s SART Name and Number] INFORMED CONSENT FOR EGG DONORS](/thumbs/39/19160563.jpg "MODEL FORM. [Program s SART Name and Number] INFORMED CONSENT FOR EGG DONORS")
MODEL FORM [Program s SART Name and Number] INFORMED CONSENT FOR EGG DONORS You are agreeing to undergo a cycle of egg donation at [program s SART name]. Do not sign this document if you have not received
Workers Compensation Program Review and Approval Authority
July 2003 Workers Compensation Program Review and Approval Authority Prepared and Edited by: Assistant Director Date UM Workers Compensation Manager Date Reviewed and Approved by: Chair - UM E, H & S Operations
The University of Texas Southwestern Medical Center CONSENT TO PARTICIPATE IN RESEARCH YOU WILL BE GIVEN A COPY OF THIS CONSENT FORM TO KEEP
The University of Texas Southwestern Medical Center CONSENT TO PARTICIPATE IN RESEARCH YOU WILL BE GIVEN A COPY OF THIS CONSENT FORM TO KEEP Title of Research: Funding Agency/Sponsor: Preventing Perinatal
CUSTOMER PRIVACY STATEMENT
CUSTOMER PRIVACY STATEMENT For Cable Television, High-Speed Internet, and Phone Services Looking for our website privacy statement? Click here. Summary of this privacy notice This privacy notice applies
Agreement for Therapy and Informed Consent
Agreement for Therapy and Informed Consent Welcome to the counseling program of St. Joseph Family Center. This Agreement for Therapy contains important information about our professional services and business
Counseling Intake Form (Each person attending therapy should complete a form)
Counseling Intake Form (Each person attending therapy should complete a form) Name Male Female Mailing Address Date of Birth Home Phone Work Email How would you like to be contacted? Home Work Email Okay
Metropolitan Living, LLC 151 W. Burnsville Parkway, Suite 101 Burnsville, MN 55337 Ph: (952) 564-3030 Fax: (651) 925-0031
The Health Insurance Portability and Accountability Act (HIPAA) and Client Privacy Statement This notice describes how your medical information may be used and disclosed and how you can get access to this
Jerry M. Ruhl Ph.D. Clinical Psychologist (Texas #34359) 5200 Montrose Blvd. Houston, TX 77006
Jerry M. Ruhl Ph.D. Clinical Psychologist (Texas #34359) 5200 Montrose Blvd. Houston, TX 77006 CELL (937) 684-7746 PLEASE USE THIS NUMBER TO SCHEDULE OR CHANGE APPOINTMENTS INFORMED CONSENT FOR TREATMENT
Ann Dunnewold, Ph.D., 2012
1 Ann Dunnewold, Ph.D. 8140 Walnut Hill Lane, Suite 100 Dallas, TX 75231 (214) 343-1353 PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT Welcome to my practice. This document (the Agreement) contains important
If you are signing for a minor child, you refers to your child throughout the consent document.
CONSENT TO PARTICIPATE IN A CLINICAL RESEARCH STUDY Adult Patient or Parent, for Minor Patient INSTITUTE: National Cancer Institute PRINCIPAL INVESTIGATOR: Raffit Hassan, M.D. STUDY TITLE: Tissue Procurement
How To Get Help From The Womens Own Day Withdrawal Management Services
Woman s Own Day Withdrawal Management Services (DWMS) UHN Information for patients and families: Read this booklet to learn: what Woman s Own Day Withdrawal Management Services is how the DWMS can help
IOM Data Privacy and Accuracy Policy
IOM Data Privacy and Accuracy Policy 1 Overview 2 Collection of information 2.1 Anonymous browsing 2.2 Candidate profile and application to vacancies 2.3 Accuracy of information 3 Use of information collected
CLIENT AGREEMENT RECITALS
CLIENT AGREEMENT This Agreement is made between Pushfit Inc., D/B/A Circadian Fitness, hereinafter referred to as Company, located at 23412 Pacific Park Dr. 17K, Aliso Viejo, CA 92656 and You, hereinafter
Document Template #1 Adult/General Informed Consent (Rev. 9/20/2011)
Document Template #1 Adult/General Informed Consent (Rev. 9/20/2011) Consent Form for Participation in the Research Study Entitled XYZ (or can be written in the XYZ study ) Funding Source: List complete
Procedures for Requests to Conduct Research
PERFORMANCE MANAGEMENT ASSESSMENT, RESEARCH & EVALUATION 5735 47th Avenue Sacramento, CA 95824 (916) 643-9420 FAX (916) 399-2050 Robin Martin, Director III Dear Researcher: The Sacramento City Unified
RE: Human Research Subject Protections Under Multiple Project Assurance (MPA) M- 1073
Office of the Secretary DEPARTMENT OF HEALTH & HUMAN SERVICES Office of Public Health and Science John M. Allen Assistant Vice President for Scientific Affairs Office of Scientific Affairs and Biotechnology
Garland s Christian Counseling Center
Garland s Christian Counseling Center : PERSONAL DATA Name: Email: Home Phone: Address: Cell Phone: Work Phone: (Street, City, Zip Code) DL #, ST & Exp : SS#: DOB: Sex: Please circle where we may leave
Consent to Treatment (Long Version) Sabrina Walters Counseling, LLC 3000 NW Stucki PL, Suite 230 Hillsboro, OR 97124 503-869-8108
Consent to Treatment (Long Version) Sabrina Walters Counseling, LLC 3000 NW Stucki PL, Suite 230 Hillsboro, OR 97124 503-869-8108 COUNSELOR-CLIENT SERVICE AGREEMENT Welcome to my practice. This document
Leonard M. Bohanon, PhD Psychologist
2203 Timberloch Pl., Suite 100 PERSONAL DATA RECORD Client Name: Date of Birth Address: City/State/Zip: Home Phone: Cell Phone: SSN: Work Phone: Other Phone: TXDL: Employer/School: Referred to Our Office
PATIENT GRIEVANCE GUIDELINES
PATIENT GRIEVANCE GUIDELINES LEGISLATIVE AUTHORITY FOR THIS PROCEDURE: Section 9335 of PL 99-509, the Omnibus Reconciliation Act of 1986 (OBRA), which amended Section 1881 (c) of the Social Security Act
REGAL MEDICAL GROUP. Important Information for Physicians Regarding Timely Access Regulations DMHC Access Standards
Important Information for Physicians Regarding Timely Access Regulations DMHC Access Standards DEFINITIONS: a. Advanced access means the provision, by an individual provider, or by the medical group or
CONSENT FORM 12/19/08
12/19/08 1001 University Place Evanston, Illinois 60201 www.northshore.org CONSENT FORM Phone (224) 364-7100 Fax (847) 570-8011 Intravesical Alkalized Lidocaine for the Treatment of Overactive Bladder
The University of Texas Southwestern Medical Center at Dallas Retina Foundation of the Southwest CONSENT TO PARTICIPATE IN RESEARCH
The University of Texas Southwestern Medical Center at Dallas Retina Foundation of the Southwest CONSENT TO PARTICIPATE IN RESEARCH Title of Research: Funding Agency/Sponsor: Study Doctors: Research Personnel:
RESEARCH SUBJECT INFORMATION AND CONSENT FORM
1 1 1 1 1 1 1 0 1 0 1 0 RESEARCH SUBJECT INFORMATION AND CONSENT FORM TITLE: PROTOCOL NR: SPONSOR: INVESTIGATOR: WIRB VCU tracking number This template is based on a drug or device research study. The
Boiling Springs Savings Bank Online Banking Access Agreement
Boiling Springs Savings Bank Online Banking Access Agreement I. Introduction II. Accessing Your Boiling Springs Savings Bank Accounts through Online Banking A. Requirements B. Electronic Mail (E-mail)
CIIS Human Research Review Committee HRRC APPLICATION PACKET
CIIS Human Research Review Committee HRRC APPLICATION PACKET BEFORE COMPLETING THE APPLICATION, you must have: A complete research proposal reviewed by your chair*. Guidance from your chair in completing
WORKERS COMPENSATION INTAKE FORM
WORKERS COMPENSATION INTAKE FORM related injury? No Yes INSURANCE INFORMATION RELEASE By clicking this box,i hereby authorize ABA Physical Therapy Associates to release to my Insurance company/attorney,
New Perspective Counseling Services Child/Teen Intake Form
Child/Teen Intake Form Welcome to New Perspective Counseling Services. We look forward to providing you with excellent and efficient counseling services. Please take a few minutes to fill out this form.
Sterman Counseling and Assessment
Information for Clients Welcome to Sterman Counseling and Assessment. We appreciate the opportunity to be of assistance to you. This packet answers some questions about therapy services. It is important
Align Counseling. Shelly Hummel, LMFT. Informed Consent for Therapy Services THERAPIST-CLIENT SERVICE AGREEMENT
Align Counseling Shelly Hummel, LMFT Informed Consent for Therapy Services THERAPIST-CLIENT SERVICE AGREEMENT Welcome to my practice. This document contains important information about my professional
NOTICE OF PRIVACY PRACTICES
Effective Date: September 23, 2013 THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. OUR PLEDGE
#3: SAMPLE CONSENT FORM
#3: SAMPLE CONSENT FORM [Key Element #3: Who is conducting the study] UPMC University of Pittsburgh Medical Center Western Psychiatric Institute and Clinic CONSENT TO ACT AS A PARTICIPANT IN A RESEARCH
Executives. Benefits. Summary. The California State University
Executives Benefits Summary The California State University January 2006 The Benefits of Working at the CSU This summary of executive perquisites, relocation benefits, and general benefits provides an
Chaffey College Disability Programs & Services LD Referral Form
Chaffey College Disability Programs & Services LD Referral Form Date: Name: Student ID#: Address: City: Zip: Phone: Alternate #: DOB: Referring DPS Counselor: Who referred you for LD testing? E-mail: 1.