How did you hear about us? (required)
Postal code (required)
Who should be contacted if there is an emergency (required)
Emergency contact phone (required)
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. 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
In some legal proceedings a judge may issue a court order. This would require this counselor to testify in court.
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 county child protection services.
If I learn of or believe that an elderly person, or disabled person is being abused or neglected, I must file a report with the appropriate state agency that handles elder abuse.
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 who you have threatened, contacting the police or placing you into hospitalization.
m.,If there is evidence that you are a danger to yourself and I believe that you are likely to hurt yourself unless protective measures are taken, I may be obligated to seek hospitalization for you or to contact family members or others who can help provide protection
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 in order 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.
If you need to cancel or reschedule your appointment, you must do so at least 24 hours in advance, or you will be charged full price for the appointment.
I understand I must give 24 hours notice when cancelling/rescheduling an appointment, or I will be charged full price for the appointment.
I have read the above confidentiality policy. I understand the nature and limits of confidentiality.
Date of signing (required)