Consent to Multiple Persons in Therapy

The undersigned, as the client or the client’s authorized representative, voluntarily consents to Multiple Persons in Therapy. This consent will remain fully effective until it is revoked in writing. 

The participants in therapy are hereby referred to as the “Treatment Unit”. For treatment delivery and confidentiality purposes, the Treatment Unit is considered to be the client. 

The Practice does not guarantee the results of  therapy. Results may vary and are dependent on multiple factors. 

Confidentiality 

The content of family therapy is confidential. You agree to keep the content of therapy sessions confidential and not share such with people outside the participants of the Treatment Unit.  

The Practice cannot guarantee that all participants of the Treatment Unit will honor confidentiality. 

If there is information that needs to be discussed among family members or with other parties outside of formal therapy sessions, participants are expected to discuss these considerations with the clinician in advance. 

No Secrets Policy 

The clinician does not keep secrets. Any communication (including electronic communication and information learned in an individual session or session with only a portion of the Treatment Unit) shared by a participating member with the clinician may be discussed with the entire Treatment unit during therapy sessions.  

The clinician will use the clinician’s clinical judgment as to whether, when, and to what extent the clinician will make such disclosures to the Treatment Unit. If appropriate, the clinician may first give you the opportunity to make such disclosures yourself.  

If you feel it necessary for you to discuss matters that you do not want to share with the entire Treatment Unit, you should consult with an individual clinician who may provide treatment to address such matters outside of Multiple Persons therapy. 

Records 

All records pertaining to Multiple Persons in Therapy belong to all the individual participants. If any individual participant makes a records request related to such therapy, all participants (and any minor participant’s parent/guardian who has medical rights to the minor) must provide a signed Authorization to Release Information before the Practice may release the requested records. 

Emergencies 

Medical and psychological emergencies should be directed to 911 if life or safety is threatened. If you feel you are in danger of hurting yourself, you should go to the nearest emergency room or call 911. If your clinician is not available when you urgently need to speak with someone, please call or text the free 24-hour Suicide and Crisis Lifeline at 988. 

Confirmation 

I confirm that I have read and fully understand the above consent and give such consent voluntarily and without coercion from any party. 

I understand that I have the right to revoke this authorization by giving written notice stating my intent to revoke this authorization to the Practice.

 I understand that my revocation of this authorization does not extend to prior actions taken in reliance on this authorization. 

Unless I have specifically requested in writing that the disclosure be made in a certain format, the Practice reserves the right to disclosure information as permitted by this authorization in any manner that the Practice deems to be appropriate and consistent with applicable law, including, but not limited to, verbally, electronically, or in paper format.

There may be a charge for copies of records. Request a copy of the Records Request and Legal Proceedings Policy for more information.

• I have read this form and agree to the uses and disclosures of the information as described.
• I understand that this authorization is voluntary and that I may refuse to sign this form. The Practice will not condition my treatment on whether I give authorization for disclosure.
• I understand that refusing to sign this form does not stop disclosure of health information that is otherwise permitted by law without my specific authorization, including disclosures to covered entities as provided by 45 C.F.R. 164.502(a)(1) and applicable state laws.
• I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state privacy laws.