Statement of Confidentiality

All interactions which take place in the setting of therapy are considered confidential. This includes requests by telephone, all interactions with this counselor, any scheduling or appointment notes, all session content records and any progress notes that I take during your sessions. I will not even verify that you are a client.

When therapy is paid for by a third party, only verification of attendance may be shared with the third party. Content of therapy may only be shared if permission to do so was granted.

You may choose to give me permission in writing to release any or specific information about you to any person or agency that you designate.

Limits to this agreement

1. In some legal proceedings a judge may issue a court order. This would require this counselor to testify in court.
2. If I learn of or believe that there is physical or sexual abuse or neglect of any person under 18 years of age, I must report this information to the child protection services.
3. If I learn of or believe that an elderly person, or disabled person or any person in a vulnerable situation, is being abused or neglected, I must file a report with the appropriate agency that handles that abuse.
4. If I learn of or believe that you are threatening serious harm to another person, I am obligated to report this. This can be in the form of telling the person whom you have threatened or contacting the police.
5. If there is evidence that you are a danger to yourself and I believe that you are likely to seriously harm yourself unless protective measure are taken, I may be obligated to seek hospitalization for you or to contact family members or others who can help provide protection.
6. There may be times when I consult with outside sources about cases. In these cases, no personally identifiable information will be used to discuss this case. However, discussion topics will be used to ensure that I am getting and giving the best assistance possible. The persons with whom I discuss cases are legally bound to keep information confidential.
7. Since I am also a clinical supervisor, I may use your case in training other therapists. In such a situation, no identifying information will be used.
8. If the case is written up for publication or academic research, no identifying information will be used.

I have read and discussed the above information with my therapist. I understand the nature and limits of confidentiality.

_______________________     Client signature  ______________________ Date