CONSENT AND INTAKE INTERVIEW FORM
The CDU-Guidance Services Office Counseling Service is committed to non-discrimination with respect to race, religion, age, gender, marital status, national origin, sexual orientation or political affiliations.
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E-Mail-Adresse *

By filling out my full name, I consent to take part in the Consultation/Counseling session provided by the CDU Guidance Services Office. 

By signing this form:

I certify that all information are true and correct to the best of my knowledge. 

I grant CDU Guidance Services Office the permission to contact the specified persons below who are at the same location as me in the event of a crisis, risk of danger, or emergency to ensure my safety.

 *
(Last Name, First Name, Middle Initial)
You may indicate at least 1 contact person
Name of Contact Person No.1 *
Relationship with Contact Person No.1 *
Cellphone Number of Contact Person No. 1 *
Name of Contact Person No.2
Relationship with Contact Person No.2
Cellphone Number of Contact Person No. 2

All GSO staff adhere to very strict confidentiality standards. The information you share during the course of the session will only be between you and your counselor. Dissemination of any information that can personally identify you shall not occur without your written consent, EXCEPT: in suspected cases of abuse, expression of harmful threats to self and others, or as required by law. In order to provide the best services possible, your counselor may consult with other counselors in the Guidance Office. Your information WILL NOT APPEAR in your academic records.


By filling out my name, I have read, understood, and agreed to the terms and guidelines stated above and have had the time to ask questions in regard to the session with my Counselor.

 *
(Last Name, First Name, Middle Initial)
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