Confidentiality Agreement
Confidentiality is one of the most important elements of psychotherapy. As your therapist I am legally bound and morally obligated, within certain legally defined limitations, to uphold and maintain your privacy and keep your personal information strictly confidential. None of your information will be revealed to any other person or agency without your written permission. However, there are specific circumstances that legally require me to reveal information obtained during psychotherapy. These circumstances include when there is a threat to yourself or others. Additionally any situation where there is a reason to be concerned about possible abuse or neglect of a child, elderly or handicapped person.
You should also be aware that if you are using a third party reimbursement, I am required to provide the insurer with a clinical diagnosis and often a treatment plan or summary.
For clients under 18 years of age, please be aware that your parents have the right to receive general information regarding your treatment and may request a summary of how treatment is proceeding. I will discuss with you and your parent(s) what specific information will and will not be shared.
Your signature below indicates that you have read and you understand the information in this agreement and agree to abide by its terms during our professional relationship.
Additionally, your signature indicates that you grant Diverse Understanding staff permission to contact the emergency contact noted above (which you can choose to change at any time) in the case of an emergency.
Community services to contact during a crisis:
Sexual and Gender Identity
If attached, please refer to genogram for family history.
Treatment Considerations
DIAGNOSIS