Individual–Confidentiality & Consent Form

I understand that all information shared with my therapist without my written consent, except in the following circumstances:
a) the information I share pertains to the physical, sexual, or emotional abuse of a minor, elderly person or an adult who is mentally or physically unable to protect his/her own rights;
b) the information I share suggests that I represent a significant danger to myself or others;
c) the records of my case are subpoenaed by a court of law, and the judge in the matter rules that the client/therapist privilege of confidentiality does not apply.

Any communications by way of email or fax will become part of my file and is subject to all rules concerning case notes. However, there can be no guarantees made about the confidentiality of communications over the internet, as some service providers and employers also monitor and archive email communications. Efforts are made to insure that client records comply with all HIPPA requirements.

Please do not text anything other than appointment times and confidentiality is not secure with texting.