A “therapist-patient” or “treatment” relationship does not exist until after initial assessment is completed and we have decided to move ahead as evidenced by your signature on this form.  It is important that we both agree that we are a good match in working together towards your goals.  We will discuss this during the first visit and decide whether or not to proceed, and whether we need to continue the assessment for one or more subsequent visits.  It is also important for you to be aware of the benefits and limitations of psychotherapy or other services you will be receiving.  While it is generally expected that you will benefit from therapy, there may be periods of feeling worse before feeling better and there is no guarantee of success in therapy.  There may be alternative treatments or modes therapy to consider.  I encourage you to be come aware of these factors and to ask any questions you may have at any time during our work together.

CONFIDENTIALITY

State law protects the confidential nature of the therapist-patient relationship, but this protection is not absolute.  I will not release clinical information to anyone unless given written permission to do so by the patient (or if the patient is a minor, by his or her parent or guardian).  However, there are a few exceptions that allow or require the release of confidential information even in the absence of patient consent.

Examples Include:

1) The therapist must act appropriately when there is danger to the patient or to another person at the patient’s hands.  This generally means that the therapist may involve others when necessary to protect the patient if he or she is suicidal or is unable to provide self-care at a level necessary for basic survival, or to prevent harm to another person.  State law also requires the reporting of abuse to or neglect of a child or an elderly or disables person when there is reason to believe it has occurred.

2) In response to a court order, the therapist must testify or release records.  However, a therapist does not release records, depose or testify in response to a subpoena unless the patient or patient’s guardian has given written authorization to do so or if the therapist is required by law to do so.

3) As professionals, we do consult with one another from time to time.  Any clinical material is conveyed without identification whenever possible.  At other times, it will be necessary (for example, if another therapist is covering calls during a vacation).  Finally, case material is sometimes used in training, research, writing, etc.  This is always done with identifying information removed and with great care and respect for your privacy.  Any other release of information requires you or your guardian’s written authorization.