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Clinical Center
625 Wham Drive Mailcode 4602
Wham Building Room 141
Carbondale, Illinois 62901
618-453-2361 | F: 618-453-6130
ClinicalCenter@SIU.edu
Main Content
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Clinical and Counseling Psychological Services
Manuals:
- General Policies and Procedures (Updated 12/2019)
- Psychological Services Manual (Updated 08/2022)
- Intake Manual (Updated 06/2021)
Intake:
- Informed Consent to Record (Verbal consent, fillable PDF)
- Telemental Health Clinician Check (Fillable PDF)
- HIPAA (Verbal consent, fillable PDF)
- Information and Consent for Treatment (Verbal consent, fillable PDF)
Assessment Screening:
- Telemental Health Clinician Check (If virtual)
- HIPAA (Verbal consent, fillable PDF)
- Authorization for Psychological Evaluation (Verbal consent, fillable PDF)
New TELEHEALTH Psychotherapy Client:
- Informed Consent to Record (Verbal consent, fillable PDF)
- Telemental Health Clinician Check (Fillable PDF)
- Information and Consent for Psychological Services (Verbal consent, fillable PDF)
- Therapist-Client Agreement (Verbal consent, fillable PDF)
New IN PERSON Psychotherapy Client:
- Informed Consent to Record
- Information and Consent for Psychological Services
- Telemental Health Clinician Check (Complete in case clients need to transition to telehealth in the future)
- Therapist-Client Agreement
Assessment Client (First Appointment IN PERSON):
Assessment Client (First Appointment VIRTUAL):
- Informed Consent to Record (Verbal consent, fillable PDF)
- Telemental Health Clinician Check (Fillable PDF)
- Authorization for Psychological Evaluation (Verbal consent, fillable PDF)
Other Forms and Documents:
- Clinical Center Release of Information (MUST BE WRITTEN SIGNATURE, verbal consent not sufficient, fillable PDF)
- Safety Plan (Fillable PDF)
- Clinical Center Recording Instructions
Speech and Language Pathology Services
Manuals:
- General Policies and Procedures (Updated 12/2019)
- Speech and Language Manual (Updated 06/2023)
- Intake Manual (Updated 06/2021)
- CDS Clinical Center Handbook (Updated 08/2022)
General Forms:
- Clinical Center Release of Information (MUST BE WRITTEN SIGNATURE, verbal consent not sufficient, fillable PDF)
- Consent to treat (MUST BE WRITTEN SIGNATURE, verbal consent not sufficient, fillable PDF)
- Hearing Evaluation Protocol (Complete IF indicated by failed hearing screening)
- Consent For Email (OPTIONAL, must be completed before exchanging email messages with client via email)
Forms to Complete Prior to Beginning Services (must be renewed each semester):
- Informed Consent to Record (Verbal consent, fillable PDF)
- Therapist-Client Agreement
- HIPAA
- Audiometric (Hearing) Screening Form
- Permission for Non-Parent/Non-Guardian to Pick Up SIU Clinical Center Client (OPTIONAL)
Forms to Completed at End of Semester:
- Client Disposition Form
Other/General Forms and Documents
(may repeat in discipline-specific sections)
- COVID-19 Precautions Letter for Assessments
- Safety Plan (Fillable PDF)
- Clinical Center Release of Information (Fillable PDF)
- Clinical Center Release of Information - Instructions (PDF)
- Reduced Fee Application (Fillable PDF)
- Clinical Center Recording Instructions
Telehealth Documents and Forms:
- Blank Psychological Encounter for training (DO NOT USE FOR CLIENTS)
- Telemental Health Plan B (PDF)
- Checklist for Telepsychology Services (PDF)
- Zoom Instructions for Clinicians (PDF)
- Zoom Instructions for Supervisors (PDF)
- Tips for Clinicians while doing Telemental Health (PDF)
Additional Resources for Telehealth
- APA Guidelines Telepsychology Practice 2013 (PDF)
- Telehealth Tip Sheet - COVID Child Version (PDF)
- SAMSHA doc (PDF)
- Keeping your Distance to Stay Safe (PDF)
- Importance of Telemedicine and Patient Eye Contact - Carbon Health (PDF)
- How to Set Up Your Office for Teletherapy Session (PDF)
New Clinician Forms:
- Student Agreement Form (PDF)
- Acknowledgement of Mandated Reporter Status Elder Abuse Form (PDF)
- Acknowledgment of Mandated Reporter Status Child Abuse Form (PDF)
- Safety Contract Form (PDF)
- New Clinician Request for Information (PDF)
- Illinois Mandated Reporter Training (Link to outside website)