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spacer spacer Disclosure Statement (MSA) Program

All Keene State students who seriously threaten or who have attempted suicide must attend a minimum of 3 safety assessment sessions at the Counseling Center or with a community therapist. The purpose of the assessment sessions is to connect the student with counseling and other resources and help him/her develop ways to stay safe while s/he is experiencing suicidal thoughts and feelings. If the use of alcohol or other substances place them at greater risk for suicide, additional sessions may be required to try to decrease the risk caused by their use. The Keene State Suicide Prevention Team (SPT) will review all reports of suicide incidents and determine which meet the threshold for referral for a mandated safety assessment (MSA).

Purpose of Disclosure Statement. Engaging in an assessment at the Student Counseling Center or with an off-campus counselor is your decision. Because we want to ensure that your decision is an informed one, we ask you to read this disclosure statement. This explains your rights and responsibilities in detail.

Authorization to Release Information Form. The Student Counseling Center services (and those of off-campus counselors) are confidential, within the limits of the law. For this reason, you are required to sign a release if you choose to complete the MSA protocol. This release enables the counselor you see to communicate to the SPT that you have followed through with your assessment. Without your written authorization, your provider cannot confirm for the SPT that you've been seen, thus you will not have met the College's requirements.

Nature of Confidentiality. Although you are required to sign a release, your counselor will only communicate whether you have completed the required three sessions to the SPT; (s)he will not reveal the content of what you've discussed, except as required by law. The special circumstances under which a counselor would be legally compelled to break confidentiality are listed below:

    Legal Responsibilities:
    We may notify appropriate authorities - for example, contacting the police, Campus Safety, Residential Life, the Vice President of Student Affairs - if it is a matter of saving your life or keeping you from killing yourself.

    We are required to warn the victim and police if a counselor knows of a client's threat to harm another person or property.

    We are required to report current child or elder abused.

    We are required by state law to report an episode of student hazing.

    We must acknowledge appropriately court orders requesting counseling records and verification of attendance when a student has been mandated.

    Professional Responsibilities:
    We are required to report to the appropriate professional associations and licensing boards if a student reveals any unethical behavior by a counselor.

Free assessment/counseling. There is no charge to students who complete their safety assessment through the Student Counseling Center. Students referred for a safety assessment have the option of completing an equivalent series of assessment sessions with a provider off campus at their own expense. If at the end of the assessment process you wish to continue counseling with your counselor or with another counselor, just let your counselor know and we will get you scheduled for on-going appointments. Counseling is supported through a student fee that all students pay, and there is no additional charge for services. Once you complete the required sessions for the safety assessment, the conditions of the limited release of information have been fulfilled and no one will be informed that you are continuing in counseling.

Intake. A student referred for the MSA will complete all of the same paperwork any new Student Counseling Center client would. The counselor will certainly be asking you in depth about suicidal feelings and behaviors in order to complete the assessment, but you are welcome to discuss other issues of concern to you as well.

Participation. Because of concerns for your safety, your full participation in this assessment is needed. This means making three appointments (in accord with your counselor's schedule). It means arriving for each appointment on time. It also means working as honestly and fully as you can. Should something unexpected occur and you need to cancel an appointment, please give us 24 hour notice and reschedule the appointment for as soon as possible. These steps are important for you to do in order to meet the requirements of your MSA.

Non-Compliance. Because your safety affects many people, not completing the MSA may affect your student status. If the Suicide Prevention Team does not receive verification of you having made an initial appointment by the date required, and/or it does not receive timely confirmation that you have engaged in a full assessment, there may be further consequences for you.

Repeated Concerns. If there are additional reports to the SPT concerning actions that put you at risk and affect the welfare of others even after you have begun or completed your three sessions, further actions to protect you and community well-being will follow. For example, you may be asked to complete another assessment with a different counselor, you may be disallowed from residing in College-owned halls or houses, or you may be dis-enrolled from your courses. Other consequences are possible as well, at the discretion of the Associate Vice President of Student Affairs.

Right to Appeal. Our hope, of course, is that you will look upon the MSA as an opportunity to discuss important issues in your life, including (but not limited to) suicidal feelings and risky behaviors. However, you may choose to appeal the SPT's decision. In order to appeal this mandated assessment, you must call the Student Development office, 358-2842, within 24 business hours to arrange for a personal appointment. The decision of the Associate Vice President regarding any appeal is final.


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