WINONA STATE UNIVERSITY by 3g92726

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									                            WINONA STATE UNIVERSITY
                             COUNSELOR EDUCATION

       CLIENT RELEASE OF INFORMATION FOR TAPE SUPERVISION



I___________________________________________________agree to be counseled by
a graduate practicum/intern student in the Counselor Education Department at Winona
State University. I further understand that I may participate in counseling interviews that
will be audio taped or video taped which will be reviewed for clinical supervision with
the student's counseling supervisor for training purposes. The tape will be erased
following the supervision session. I understand that a graduate student who has
completed advanced course work in counseling will counsel me. I understand that a
faculty member (university supervisor) will supervise the student.

Client Signature:_____________________________________________

Date:________________________________

Counselor's Signature__________________________________________

Effective Date:_______________________________________________

This contract Expires:__________________________________________

								
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