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

  1. The client reveals information about hurting himself/herself or another person.
  2. The client or another person may be in physical danger.
  3. 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.
  4. A court order issued by a judge may require the release information contained in your records.
  5. 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________________

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