Limits of Confidentiality
Contents of all therapy sessions are considered to be confidential. Both verbal information and written records about a patient cannot be shared with another party without the written consent of the patient or the patient's legal guardian. Noted exceptions are as follows:
Duty to Warn and Protect
When a patient discloses intentions or a plan to harm another person, the mental health professional is required to warn the intended victim and report this information to legal authorities. In cases in which the patient discloses or implies a plan for suicide, the health care professional is required to notify legal authorities and make reasonable attempts to notify the family of the patient.
Abuse of Children and Vulnerable Adults
If a patient states or suggests that he or she is abusing a child (or vulnerable adult) or has recently abused a child (or vulnerable adult), or a child (or vulnerable adult) is in danger of abuse, the mental health professional is required to report this information to the appropriate social service and/or legal authorities.
Prenatal Exposure to Controlled Substances
Mental Health care professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful.
Parents or legal guardians of non-emancipated minor patients have the right to access the patients' records.
Insurance Providers (when applicable)
Insurance companies and other third-party payers are given information that they request regarding services to patients. Information that may be requested includes type of services, dates/times of services, diagnosis, treatment plan, and description of impairment, progress of therapy, case notes, and summaries.
I agree to the above limits of confidentiality and understand their meanings and ramifications.
Signature (Patient's Parent/Guardian if under 18)
Should be Empty: