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:


  1. 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.
  2. 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.
  3. 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.
  4. In cases of alleged criminal or civil liability, I may be court ordered to release treatment information.
  5. Some confidentiality will be lost in the insurance billing process, although every effort will be made to minimize the amount of information shared.
  6. 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.
  7. I may release your name for collections processing, but no treatment information will be released.


Emergency Coverage:

You may leave messages for me 24 hours / day at 314-651-8290 or email me at

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:______________________________




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