Clients are assured of confidentiality unless you sign a release of information allowing me to discuss information with another individual or agency. There are some important exceptions where I am required by law to release information without your permission:
- If I judge that a client intends to cause serious bodily harm or kill another person, the law requires me to notify the intended victim and the appropriate law enforcement agencies.
- I am required to report any suspected child abuse, neglect, or molestation to protect the child/children involved. I am also required to report any suspected abuse, neglect, or molestation of an elderly person or dependent adult.
- If I assess a client to be suicidal, I am required by law to notify the individuals or agencies necessary to prevent self-harm, including initiating hospitalization on an involuntary basis if necessary.
- In cases of alleged criminal or civil liability, I may be court ordered to release treatment information.
- Some confidentiality will be lost in the insurance billing process, although every effort will be made to minimize the amount of information shared.
- I may determine that it is necessary to discuss some aspects of your therapy with another qualified professional to help further your treatment goals. If I do seek consultation, neither your name nor any other identifying information will be used.
- I may release your name for collections processing, but no treatment information will be released.
You may leave messages for me 24 hours / day at 314-651-8290 or email me at firstname.lastname@example.org.
In the event of an emergency, please call 911 or go to the nearest emergency room.
I have reviewed and understand the information above.
Signed: ____________________________________________________________ Date:______________________________
Witness: ___________________________________________________________ Date:______________________________