Confidentiality
The Limits of Confidentiality
Communication between a therapist and patient are considered “privileged” which means that the content may not be revealed unless you give written permission.  However, there are a few exceptions to this:
1.  You sign a release authorizing your information to be shared with someone.
2. If you come to me for a court ordered evaluation, I am required to provide the evaluation to the court.
3. I am subpoenaed.  This rarely happens and won’t happen without your knowledge.  
4. I am required by law to report any suspicion or incident of child abuse, molestation, neglect, or abandonment.
5. I am required by law to report any suspicion or incident of elder abuse, molestation, neglect, or abandonment.
6. I am required by law to report intent to commit suicide or homicide.
7. I am required by law to report knowledge of a crime.  

Your signature below indicates that you have read and understand the limits of confidentiality.


Sign in to Google to save your progress. Learn more
Email *
By entering my name into the signature field below, I agree that it constitutes my electronic signature and is the equivalent, and has the same force and effect, of my handwritten signature.                                               Please type your name and today's date below *
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy