Confidentiality Consent Form

All information shared in counseling sessions is treated as private and confidential. This means your personal disclosures are not shared outside of Mental Health Rescue LLC without your written consent, except in certain legal or ethical situations described below.

 

Danger to Self: If you express intent to harm yourself, your provider may need to take steps to ensure your safety, which could include notifying appropriate parties.

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.

Danger to Others: If you threaten harm to someone else, your provider may be required to warn the potential victim and/or notify authorities.

Prenatal Exposure to Controlled Substances: Mental Health care professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful.

Minors/Guardianship: Parents or legal guardians of non-emancipated minor patients have the right to access the patients' records.

Abuse or Neglect: Disclosure of child, elder, or dependent adult abuse or neglect must be reported to appropriate agencies by law.

Court Orders/Subpoenas: If a court orders the release of your records, your provider must comply as required by law.

Supervision/Consultation: To ensure quality care, your case may be discussed confidentially with supervisors or consultants.

Insurance/Billing: Some information may be shared with your insurance company or billing service as necessary for payment or authorization.

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.

Electronic communication (such as email or text messaging) may not be fully secure. While efforts are made to protect your privacy, there is some risk that information could be accessed by unauthorized parties. Please discuss any concerns about electronic communication with your provider.

In group or family counseling, confidentiality cannot be guaranteed by the provider for what other participants may share outside the session. All participants are encouraged to respect each other's privacy.