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You are here : Treatment
December 09, 2018
Limits on Confidentiality

The law protects the privacy of all communications between a client and a Counselor.  In most situations, we can only release information about your treatment to others if you sign a written Authorization form. 

Your signature on the Agreement form we provide allows consent for those activities, as follows:  

  •  I (we)  may occasionally find it helpful to consult other pastoral, health and mental health professionals about a case.  During a consultation, I (we) make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel that it is important to our work together. 
  • If a client seriously threatens to harm himself/herself, we are obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. 
  •  If I (we) have cause to believe that a child under 18 has been or may be abused or neglected (including physical injury, substantial threat of harm, mental or emotional injury, or any kind of sexual contact or conduct), or that a child is a victim of a sexual offense, or that an elderly or disabled person is in a state of abuse, neglect or exploitation, the law requires that I make a report to the appropriate governmental agency.  Once such report is filed, I (we) may be required to provide additional information. 
  •  If I (we) determine that there is a probability that the patient will inflict imminent physical injury on another or others, I (we)may be required to take protective action by disclosing information to medical or law enforcement personnel or by securing hospitalization of the patient.

If such a situation arises, I (we) will make every effort to fully discuss it with you before taking any action and I (we) will limit my disclosure to what is necessary. 

It is important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, and we are not an attorney. In situations where specific advice is required, formal legal advice may be needed.

You should be aware that I keep protected Case Records. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, your billing records, and case notes.

Download this PDF, print and sign it.  Please bring this form with you to your first session. 

Client Consent Form