Counseling is based on a trusting relationship between counselor and client. The success of counseling is built on a trusting relationship between the counselor and the client that begins confidentiality of information shared. I treat the personal information you share with me with the highest level of respect and confidentiality. I will keep your disclosures between the two of us and will your written or explicit permission to share. I will keep the information you share confidential, except in certain situations in which an ethical or legal responsibility limits confidentiality.
Exceptions to Confidentiality
- The client reveals information about hurting himself/herself or another person.
- The client or another person may be in physical danger.
- If there is suspected physical or sexual abuse, or neglect of a child or vulnerable person, I am compelled to report this information to child protective services.
- A court order issued by a judge may require the release information contained in your records.
- Information may be shared with other appropriate staff, or professional service providers.
I have read and understand the information provided in this document. I understand the benefits and risk of counseling and the nature and limits of confidentiality. I also understand the expectations of the client.
By signing this form, I give my informed consent to participate in counseling therapy. I understand that anything that the client shares will be kept confidential except in the above-mentioned cases.
I ________________________________, understand and consent to conditions and confidentiality laws and regulations mentioned in this document.
Printed Name ________________________________ Date ________________
Client Signature _________________________________ Date ________________
Counselor Signature_______________________________ Date________________