RESPONSIBILITY AGREEMENT (LEGAL WAIVER)
HEALTH / MEDICAL ADVICE
During our therapy sessions, I may provide some information on medications, supplements, tools and practices intended to support your mental, emotional, physical and spiritual health. As I am not a doctor, naturopath or physiotherapist, I can't officially prescribe any of these medications, supplements, tools or practices to you as part of a treatment plan. It is your responsibility to do your own research and make an informed decision regarding all recommendations. All suggestions are completely optional.
CONFIDENTIALITY CONCERNS
In general, the privacy of all communications between a client (you) and the therapist (myself) is protected by law and I can only release information about our work to others with your written permission, but there are a few exceptions. There are some situations in which I am legally obligated to take action to protect others from harm, even if I have to reveal some of the information that we have discussed. For example, if I believe that a child, elderly person, or disabled person is being abused or has been abused, I may be required to make a report to the appropriate government agency. If I believe a client is threatening serious bodily harm to another, I may be required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the client. If you (the client) threaten to harm yourself, I may be obligated to seek hospitalization for you or to contact family members who can help provide protection. If such a situation occurs in the course of our work together, I will attempt to fully discuss it with you before taking any action. Although this written summary of exceptions to confidentiality is intended to inform you about potential issues that could arise, it is important that we discuss any questions or concerns that you have. I will be happy to discuss these issues with you and provide clarification when possible. However, if you need specific clarification or advice I am unable to provide, formal legal advice may be needed, as the laws governing confidentiality are quite complex and I am not an attorney.
ACKNOWLEDING YOUR RESPONSIBILITY
By signing this document you acknowledge that I (Dareau Debrecen) do not regard myself as a medical professional, and that I (Dareau Debrecen) am not taking responsibility for your mental, emotional or physical wellbeing.
By signing this document you are acknowledging and claiming full responsibility for your own thoughts, feelings, and decisions. By signing this document you are
waiving any and all rights you have, or that anybody else has on your behalf to hold me, AVI Health Center, or its employees, responsible for any mental, emotional or physical harm that may come about in, or outside, of our work together.
Your signature below indicates that you have read the information in this document and agree to abide by its terms.