LIMITS
OF CONFIDENTIALITY Contents
of all therapy sessions are considered to be
confidential. Both verbal information and written records
about a client cannot be shared with another party
without the written consent of the client or the client’s
legal guardian. Noted exceptions are as follows: Duty
to Warn and Protect When
a client 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 client 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
client. Abuse
of Children and Vulnerable Adults If
a client 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. 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 clients have
the right to access the clients’ records. Insurance
Providers (when applicable) Insurance
companies and other third-party payers are given
information that they request regarding services to
clients. 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. I
agree to the above limits of confidentiality and
understand their meanings and ramifications. _________________________________________________________________ Client
Signature (Client’s Parent/Guardian if under 18) ________________________________ Today’s
Date
CANCELLATION
POLICY If
you fail to cancel a scheduled appointment, we cannot use
this time for another client and you will be billed for
the entire cost of your missed appointment. A full fee of
is charged for missed appointments or no show
cancellations with less than a 24 hour notice unless due
to illness or an emergency. A bill will be mailed
directly to all clients who do not show up for or cancel
an appointment. Thank you for your consideration
regarding this important matter. _________________________________________________________________ Client
Signature (Client’s Parent/Guardian if under 18) ________________________________ Today’s
Date |