Upward Bound Counseling Services

Informed Consent 
Purpose of Services:  Upward Bound Counseling Services exist to provide students in the program with psychological and psychoeducational support services to help them function successfully in their academic lives. When students are faces with excessive stress of difficult personal problems, professional help may be helpful and necessary. Services include assessment, personal and career counseling, skills workshops and support groups. Students in need of extended or more intensive clinical services may be referred to outside clinical providers. 
Staff: The Upward Bound Counselor providing services is licensed in the state of New Mexico and skilled in the provision of psychotherapy and psychoeducational support services. Your are welcome to ask the counselor about her/his professional qualifications. 

Confidentiality: Confidentiality within the UNM-Valencia Campus Upward Bound Counseling Services is considered essential. Information provided during individual and group sessions will not be released without a signed authorization from the participant's legal parent or guardian. Authorization for Release of Information forms may be obtained form the counselor. If a legal parent or guardian wishes to review their child's record, it is required that records are reviewed in the presence of the counselor and participant. This allows the parent or guardian the opportunity to ask questions. PLEASE NOTE: There are legal and ethical exceptions to confidentiality that requiere counselors to take responsible action and release information provided during counseling sessions without the parent or guardian's permission. They are: 

  • Imminent threat of harm to the participant or others
  • Suspected child or elderly abuse
  • Court orders from a judge
Fees: Counseling services are free to all Upward Bound participants. This is a service provided by the Upward Bound grant to facilitate a participant's academic success. 
By signing this form, you acknowledge that you have read and understood the preceding information. 
Signature of Parent/Guardian: *
Signature Type: SMS    Start Over
After validation, the cell phone number will become part of the electronic signature.
Cell Phone Number:

Date: *
Name: ( First, Middle, and Last Name) *
Participant Signature: *
Signature Type: SMS    Start Over
After validation, the cell phone number will become part of the electronic signature.
Cell Phone Number:

Date: *
Name: ( First, Middle, and Last Name) *
High School Name: *