Assessment Consent Form
(some light listening music as you read)
((OOC: *note: it is important you read the full message below before you begin))
Hello. Thank you for coming in today. Before we begin, it is important that you know a little bit about me and my droid, JC-33, how this process works, and some confidentiality issues that are set in place to protect us both.
As you may know, my name is Stymie, and I am serving the Reconstructed Galactic Empire as an Imperial Jedi Consular. As a Jedi Consular, I have been trained to provide psychotherapy services to both Force sensitive and non-Force sensitive beings.
My droid, JC-33, is also specifically programmed in over four million forms of both psychiatric and psychotherapeutic forms of interventions, treatments (including the administration of psychotropic medication, if necessary), and assessments, among other things.
He serves in my stead when I am away or when I have more clients (I prefer the term clients in lieu of patient) than I am able to devote my complete attention to in order to provide competent services.
All clients must first fill out an intake assessment form (OOC: coming soon). Depending on the reason you are here for services, the exact process will differ. Individual therapy sessions last fifty minutes (OOC: this does not have to be in "real" time; we can go longer, shorter, or some other arrangement depending on our availabilities). In individual therapy, we will work together to help you work through any personal conflicts and/or psychological disorders.
I want to emphasize that "we will work together." I see psychotherapy of a collaborative process between the client and the therapist.
Mandatory Imperial psychological assessment evaluations operate differently. All members of the Empire are required to report for a psychological assessment in order to be declared officially fit for duty (by order and enforcement of The Empress). Along with the intake assessment, the psychological evaluation consists of a battery of psychological test in order to determine your psychological fitness for service in the Empire. After you have completed the assessment, you will meet with a therapist, Stymie or JC-33, to review your test results and discuss any other pertinent issues. For evaluations, subsequent sessions may be required, at the discretion of Stymie and/or The Empress.
We also provide group psychotherapy services, vocational rehabilitation, Imperial career counseling, and readjustment counseling for Imperial veterans, among other things.
Other things to be aware of: 1) therapy between two Force sensitive beings often operates differently than therapy where The Force is not involved, due to the fact that the parties involved may sense each others' emotions, among other things, through The Force. 2) Stymie is partly Zeltron and therefore is more fully able to instinctively sense the emotions of others. He may also, at times, purposefully manipulate a client's emotions with pheromones or The Force in order to elicit an emotional reaction that is intended to help a client cope with difficult emotions and/or thoughts that a client may otherwise not want to confront or may be avoiding (be it consciously or unconsciously).
Confidentiality Issues:
Every thing discussed in session is confidential between the therapist and client in order to provide an environment where the client feels safe to freely express her/his/its concerns.
That being said, The Empress and/or Executer Lonefire may choose to review your file at any time. For assessment evaluations, I am obligated to report the test results to The Empress and/or Executer Lonefire.
For individual therapy session, I may request that sessions be granted guranteed privacy status between the counselor and the therapist in order to facilitate full disclosure and trust from the client, which provides the most effective means to helping a client work through her/his/its issues.
However, and this is important, if you give me any reason to believe you may present a danger to a child, I am required to report that information. If you give me any reason to believe you may be a danger to yourself or another being (unless you have been ordered to do so), I am required to report that information. If you give me any reason to believe you may be a danger to Imperial property and/or engage in treasonous activities, I am required to report that information. Finally, in the even an Imperial court orders session information, I may be required to provide session information to the courts.
Sign here to verify that you have read and understand the above information and consent to Imperial psychological services:_________________________
((OOC: to "sign" your consent, copy and paste your "consent signature (including this last OOC information--it is important you include the disclaimer in your e-signature) in my comments box below (see my example "signature" below), which will serve as your e-signature. **Important disclaimer (must be included with your "signature"): your e-signature also is verification that you fully understand that this is a fictional role-play therapy session, and I, the real person who plays the roles of Stymie and JC-33, am not responsible for any potential psychological discomfort or trauma that may result from engaging in fictional therapy**))
http://tinyurl.com/Consent-Form
Updated December 6, 2008
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((OOC: to "sign" your consent, copy and paste your "consent signature (including this last OOC information--it is important you include the disclaimer in your e-signature) in my comments box below (see my example "signature" below), which will serve as your e-signature. **Important disclaimer (must be included with your "signature"): your e-signature also is verification that you fully understand that this is a fictional role-play therapy session, and I, the real person who plays the roles of Stymie and JC-33, am not responsible for any potential psychological discomfort or trauma that may result from engaging in fictional therapy**))
((OOC: to "sign" your consent, copy and paste your "consent signature (including this last OOC information--it is important you include the disclaimer in your e-signature) in my comments box below (see my example "signature" below), which will serve as your e-signature. **Important disclaimer (must be included with your "signature"): your e-signature also is verification that you fully understand that this is a fictional role-play therapy session, and I, the real person who plays the roles of Stymie and JC-33, am not responsible for any potential psychological discomfort or trauma that may result from engaging in fictional therapy**))
((OOC: to "sign" your consent, copy and paste your "consent signature (including this last OOC information--it is important you include the disclaimer in your e-signature) in my comments box below (see my example "signature" below), which will serve as your e-signature. **Important disclaimer (must be included with your "signature"): your e-signature also is verification that you fully understand that this is a fictional role-play therapy session, and I, the real person who plays the roles of Stymie and JC-33, am not responsible for any potential psychological discomfort or trauma that may result from engaging in fictional therapy**))
((OOC: to "sign" your consent, copy and paste your "consent signature (including this last OOC information--it is important you include the disclaimer in your e-signature) in my comments box below (see my example "signature" below), which will serve as your e-signature. **Important disclaimer (must be included with your "signature"): your e-signature also is verification that you fully understand that this is a fictional role-play therapy session, and I, the real person who plays the roles of Stymie and JC-33, am not responsible for any potential psychological discomfort or trauma that may result from engaging in fictional therapy**))
((OOC: to "sign" your consent, copy and paste your "consent signature (including this last OOC information--it is important you include the disclaimer in your e-signature) in my comments box below (see my example "signature" below), which will serve as your e-signature. **Important disclaimer (must be included with your "signature"): your e-signature also is verification that you fully understand that this is a fictional role-play therapy session, and I, the real person who plays the roles of Stymie and JC-33, am not responsible for any potential psychological discomfort or trauma that may result from engaging in fictional therapy**))
((OOC: to "sign" your consent, copy and paste your "consent signature (including this last OOC information--it is important you include the disclaimer in your e-signature) in my comments box below (see my example "signature" below), which will serve as your e-signature. **Important disclaimer (must be included with your "signature"): your e-signature also is verification that you fully understand that this is a fictional role-play therapy session, and I, the real person who plays the roles of Stymie and JC-33, am not responsible for any potential psychological discomfort or trauma that may result from engaging in fictional therapy**))
((OOC: to "sign" your consent, copy and paste your "consent signature (including this last OOC information--it is important you include the disclaimer in your e-signature) in my comments box below (see my example "signature" below), which will serve as your e-signature. **Important disclaimer (must be included with your "signature"): your e-signature also is verification that you fully understand that this is a fictional role-play therapy session, and I, the real person who plays the roles of Stymie and JC-33, am not responsible for any potential psychological discomfort or trauma that may result from engaging in fictional therapy**))
((OOC: to "sign" your consent, copy and paste your "consent signature (including this last OOC information--it is important you include the disclaimer in your e-signature) in my comments box below (see my example "signature" below), which will serve as your e-signature. **Important disclaimer (must be included with your "signature"): your e-signature also is verification that you fully understand that this is a fictional role-play therapy session, and I, the real person who plays the roles of Stymie and JC-33, am not responsible for any potential psychological discomfort or trauma that may result from engaging in fictional therapy**))
((OOC: to "sign" your consent, copy and paste your "consent signature (including this last OOC information--it is important you include the disclaimer in your e-signature) in my comments box below (see my example "signature" below), which will serve as your e-signature. **Important disclaimer (must be included with your "signature"): your e-signature also is verification that you fully understand that this is a fictional role-play therapy session, and I, the real person who plays the roles of Stymie and JC-33, am not responsible for any potential psychological discomfort or trauma that may result from engaging in fictional therapy**))
((OOC: to "sign" your consent, copy and paste your "consent signature (including this last OOC information--it is important you include the disclaimer in your e-signature) in my comments box below (see my example "signature" below), which will serve as your e-signature. **Important disclaimer (must be included with your "signature"): your e-signature also is verification that you fully understand that this is a fictional role-play therapy session, and I, the real person who plays the roles of Stymie and JC-33, am not responsible for any potential psychological discomfort or trauma that may result from engaging in fictional therapy**))