This  policy is intended to inform you, the participants in family therapy, that I consider that the family referred hereby as the treatment unit,to be the patient. For instance, if there is a written request for the treatment records of the treatment unit, I will seek the authorization of all members over 18 before releasing confidential information to third parties.

During the course of my work with a family, I may see a smaller part of the treatment unit (e.g. an individual or two siblings) for one or more sessions. These sessions should be seen by you as part of the work that I am doing with the treatment unit, unless otherwise indicated. If you are involved in one or more of such sessions with me, please understand that generally these sessions are confidential in the sense that I will not release any confidential information to a third party unless I am required by law to do so or unless I have your written authorization. In fact, since these sessions can and should be considered as part of the family therapy, I would also seek the authorization of the other individuals (age 18 and over) in the treatment unit before releasing confidential information to a third party.

When there is a disagreement between adults as to what I am able to release I will be forced to extract a summary of the individual’s participation from the family notes.This may take weeks,and out of necessity,will be out of context. Alternatively,the actual session notes can be copied with necessary parties blocked out. The full fees wouldbe charged and the person requesting these documentsmust pay in full before the summary or notes will be released. Please note that in Ohio non-custodial parents are entitled to information on the biological/adopted children.

However, I may need to share information learned in an individual session, or a session with only a portion of the treatment unit being present, with the entiretreatmentunit if I am to effectively serve the unit being treated. I will use my best judgment as to whether, when and to what extent I will make these disclosures, and mayalso, if appropriate, first give the individual the opportunity to make the disclosure themselves. Thus, if you feel it necessary to talk to me about matters that you absolutely do not want shared with anyone, you might want to consult with an individual therapist who will treat you one on one.

My“no secrets” policy is intended to allow me to continue to treat the unit by preventing a conflict of interest to arise where an individual’s interest may not be consistent with the interests of the entire unit being treated. For instance, information learned in the course of an individual session may be relevant or even essential to the proper treatment of the family. If I am not free to exercise my clinical judgment regarding the need to bring this information tothe familyduring their therapy, I maybe placed in a situation where I will have to terminate treatment of the entire unit. This policy isin placeto prevent the need for such a termination.

 

I acknowledge by my individual signatures below, that I have  read this policy, that I understand it, that I have had an opportunity to discuss its contents with my therapist, and that I enter family/other therapy in agreement with this policy.

I, the undersigned, hereby authorize a representative of Compass Point Counseling Service to use and/or disclose information from medical or financial record as specified above.

I understand and acknowledge that this authorization extends to all or any part of the records designated above, which may include documentation of treatment for mental health disorders, alcohol/drug abuse or dependence, and/or HIV/AIDs test results or diagnosis.  I explicitly consent to the release of information as designated about.  Furthermore, I consent to the release of the facsimile transmission of my protected health information as necessary.

This authorization may be revoked at any time to the extent that use and/or disclosure has not already occurred prior to your request for revocation.  In order to revoke the authorization the individual/parent/legal guardian must submit a revocation request in writing to the disclosure.  I also understand that Compass Point Counseling Services may charge a reasonable fee for the preparation, copying and postage as allowed by state law for copies of medical records.

I understand that Compass Point Counseling Services will not condition treatment, payment, enrollment or eligibility for benefits on the execution of this authorization.  If the person/entity that received the above PHI is not a health care provider/health plan covered by federal privacy regulations, the PHI described above may be re-disclosed by such person/entity and will likely no longer be protected by the federal privacy regulations.

I understand that if I am requesting my physical records to be released to myself or another person/organization, I will need to complete an additional form titled Records Release Form.