Waiver of Liability and Confidentiality
I am aware that all statements I shall make are of a confidential nature, including all written information, and ethically may not be disclosed without my written consent with the following exceptions that will result in confidentiality being waived:
- A therapist working with an adult, adolescent, or a child is required by law to disclose to the appropriate person, agency or civil authority any harm that a person may attempt or desire to do to one’s self or to others, and is required to disclose any reasonable suspicion of physical or sexual abuse being done or having been done to a minor child or a dependent person.
- Although the courts usually hold psychotherapy records as privileged, therapists are professionally bound to comply with subpoenas given by a court of law.
I acknowledge responsibility for all fees incurred and should collection of my account become necessary, I will be responsible for all costs of litigation including attorney’s fees. If payment for services is not received within 3 months of services rendered, then I understand that a collection agency will be notified. By providing my signature, I acknowledge that I have read, understood, and have agreed to the Psychotherapy Guidelines, the Waiver of Liability and Confidentiality, and that I accept the stated conditions and limits of confidentiality.