CONFIDENTIALITY AND INFORMED CONSENT AGREEMENT FOR SERVICES

Confidentiality Agreement And Informed Consent Agreement For Services

Licensed Counselor Signature: _____________________________ Agency Supervisor Signature: _____________________________ Date of Discourse with the Client or Responsible Party (acting on the clients behalf): __________________________

Confidentiality Agreement What You Should Know About Confidentiality in Therapy I will perform my duties as counselor within the scope of my profession. My professional ethics are the guidelines for moral behavior and the laws of Georgia, preclude me from revealing to anyone else what you express to me unless you give me in writing - permission. These factors and State laws are the basis by which I will conduct and uphold the "confidentiality" within therapy. However, there are some areas where some information is State mandated that I must or may be required to disclose or reveal to someone else. There are certain boundaries on our confidentiality. We must discuss these, because it is in your best interest to realize clearly what I can, can not, and will not keep confidential. You are being told now, so that we can avoid the potential for you not being fully informed. These are very essential items, so please read these pages cautiously and keep this copy for your records. At our next session, we can deal with any questions you may have. 1. When you or other persons are in physical danger, the law necessitates that I to tell others about it immediately. Specifically: a. Harm to an individual or public safety: Requires that I tell the person and the police, or perhaps try to have you put in a hospital. b. Harm to yourself: Requires that I may have to seek a hospital for you, or call on your family members or others who can help protect and assist you. If such a situation does happen, I will tell you directly what I plan to do, unless there is a very strong reason not to. c. Life or Death situations: I will try to obtain your consent, but if necessary I will inform other health care professionals about your treatment. In cases where adult or child protection must be involved - wherein if I think you are a victim of abuse, neglect, self-neglect or exploitation, I will take steps to see that you are protected. d. Child abuse or neglected: As a health care professional, I am bound by State law to tell the authorities immediately. To "abuse" means to neglect, hurt or sexually molest another person. I am not an attorney, therefore you should be aware that the state agency will investigate. Circumstances may be such that we should discuss the legal aspects in detail before you tell me anything about these topics. You may also want to talk to your attorney. I will not disclose any information that does not pertain to the current situation; therefore all of what you have informed me of will not be disclosed. 2. Court proceedings: You have a right to have my testimony stopped due to therapist-client-privilege; however, certain circumstances will out-weigh the therapist-client-privilege: a. Child custody or adoption proceedings, parental ability is questioned. b. Court needs to evaluate your emotional and mental state. c. Malpractice case or an investigation of me or another therapist by a professional group. d. Civil commitment hearing and psychiatric hospitalization is considered. e. Court-ordered evaluations or treatment. The court is privy to anything you discuss. So you should be aware that what- you dont want me or the court to know- in this instance- you should keep to yourself.

CONFIDENTIALITY AND INFORMED CONSENT AGREEMENT FOR SERVICES

3. There are a few other things you must know about confidentiality and your treatment: a. I will sometimes consult (talk) with other professionals and also my Supervisor about your treatment. This other person will follow the same ethical and State statutes. I must give him or her some information about my clients, like you. b. Record keeping of your treatment, e.g. the notes I take when we meet will be also tightly controlled. You have a right to critical review of these records with me. If something in the record could lead you to become upset, psychotic, or harmful to yourself or others, I will leave it out, but I will amply explicate and state the reasons to you. 4. Insurance and money matters: a. Health Insurance: Insurance companies require some information about our therapy, as does Federal Medicaid utilization reviewers. Criterion for what is required varies from insurer to insurer. When a treatment plan is petitioned, we will discuss this during our meeting. I cannot dictate or determine how they use, store or transmit on converse with you or any other parties regarding this content. b. Insurance companies should be informed when you seek to file a claim, (this does apply if you are using Medicaid to pay for services) and all billing and document forms will be provided at the time of service. Insurers can not release your information outside of its ethical and legal scope. However, many new laws have been legislated which make it possible for insurers to circumvent this rule, and it is best that you discuss this with your insurer, and an attorney. c. Employee Assistance Program or Employer Referral: Both can ask for some information. We will discuss this in detail if this is your situation. d. Unpaid bills: You will have an opportunity to set up a defrayal/payment plan, I can and will use legal means to get paid. The only subject matter I will give to the judicial system, a collection agency, or a lawyer will be your name and address, the dates we met for professional services, and the sum of money due to me. 5. Children and Families Issues: a. Children under the age of 12: Parents or guardians will be informed of all information obtained within therapy. Children age 12 to 18: Most information will be held within confidentiality rules established by the States and my professional ethics standards. Parents and guardians will be informed regarding the status of the therapy, and if relevant information is disclosed about critical issues involving others, including family, this will be disclosed as well. If there is evidence of self-harm, danger, or harm to others, I will disclose this information to the parents and guardians, and the necessary authorities to mediate and or alleviate the crisis. b. Family Counseling: we will establish parameters for disclosure, because confidentiality will be based on each individual involved. c. Marital Issues within Family Counseling: If you disclose information which will result in harm for the other party, I will inform the other party immediately. d. Custody dispute/Court custody hearing: I need to know immediately. I can not provide both therapy and custody evaluations based on the professional ethics of the State. e. Marriage Counseling: I will not testify for either party if requested during a divorce proceeding, unless serious harm was evident from one party to another. If written information is requested, both parties must sign for the release of information. The court can order me to testify during a custody hearing. f. Family treatment requires each member to sign a consent and release form.

CONFIDENTIALITY AND INFORMED CONSENT AGREEMENT FOR SERVICES

6. Other issues to consider: a. No audiotape or videotape will be used without your written permission. b. A release of information form must be signed for me to send and any information to other parties. I will provided you with a copy today, if indicated, by your initial here _____________. c. The court does not view public or private information you reveal outside of therapy as confidential. The laws and rules on confidentiality are complex. Situations that are not mentioned here should be reviewed with your attorney. I will not offer legal advise. The signatures here show that this agreement shall be enforceable for one year from the date of this agreement, and that we have read, talked about, infer, understand, and consent to adhere to the components conferred above. ____________________________________ Client signature (or person acting for client) ____________________________________ Printed name Relationship to Client: Self Child Parent or guardian ________________ Date