130-34 Conflict of Interest and Private Practice

130-34 Conflict of Interest and Private Practice

Attachment 1-Notice to UCD Students

Notice to UC Davis Students Regarding Dual Role Psychologist or Counselor

The purpose of thisnotice is to advise you prior to beginning a therapist-client relationship of the following:

(1)I, ______, am currently employed as a Psychologist or Counselor at the University of California Davis Student Health and Counseling Services (SHCS).

(2)SHCS professional mental health staff is prohibited from referringUC Davis students they treatat SHCS Counseling Services to their private practice. However, SHCS mental health professionals may see UC Davis students in their private practice, if:

1. the student has no previous established therapeutic relationship with the provider at SHCS; and
2. the student contacts the provider directly at his/her private practice location; and
3. the student has been informed of his/her eligibility for services at SHCS, and elects to seek care with a community mental health provider.

I am required to inform you that, as a registered UC Davis student, you may be eligible to receive no cost mental health assessment and treatment at SHCS Counseling Services. Counseling Services provides confidential, short-term (average of about 5 sessions) mental health services to UC Davis students. When a student is seen at Counseling Services, the individual student’s therapeutic goals and counseling needs are considered, and the student may be referred to the Counseling Services group therapy program, or to community providers for ongoing treatment. Most UC Davis students seek services with a mental health provider in the community because they desire longer term services than cannot typically be provided at Counseling Services, due to the average session limit being about 5 sessions per academic year.

By your signature below, you are indicating that: (1) you understand SHCS Counseling Services offers no cost confidential mental health services to all registered UC Davis students, and that you may be eligible to receive those services; (2) you have been informed of these services and provided information on how to access services at SHCS Counseling Services; and (3) you have read and understood this notice and you have had sufficient opportunity to ask questions about, and seek clarification of anything unclear to you; and (4) I provided you with a copy of this statement.

By my signature, I acknowledge that I have read and understand this notice.

______

Client Signature Date

______

Therapist Signature Date