Collateral Participation Authorization and Informed Consent
Introduction
I want to thank you for accepting the invitation to assist in _________________________’s psychotherapeutic treatment. Your participation is important. This document is to inform you about the risks, rights and responsibilities of your participation as a collateral participant. (Type name of client below).
Who is a Collateral Participant?
A collateral is a spouse or partner, family member, or friend who participates in therapy to assist the identified client. The collateral is not considered to be a client and is not the subject of the treatment. Psychotherapists have certain legal and ethical responsibilities to their clients, and the privacy of this relationship is given legal protection. My primary responsibility is to my client, and I must place their interests first. They have more privacy protection; you will have less privacy protection.
A Collateral Participant's Role in Therapy
The role of a collateral will vary greatly. For example, a collateral might attend only one session, either alone or with the client, to provide information to the therapist. Or, a collateral might attend a number of the client’s therapy sessions and the relationship between the client and the collateral relationship may be one focus of treatment. We will discuss your specific role in the treatment at our first meeting and other appropriate times.

Benefits and Risks
Psychotherapy often focuses on intense, emotional experiences, and your participation may engender strong anxiety or emotional distress. It may expose or create tension in your relationship with the client. While your participation can result in better understanding of the client and an improved relationship, and may even help your own growth and development, there is no guarantee that this will be the case. Many people initially feel worse when they begin therapy before they feel better.
Medical Records
As a collateral, no record or chart will be maintained on you. However, notes about you and your participation may be entered into the client’s chart- the client’s Protected Health Information (PHI). The PHI of the client will be stored in a locked cabinet in my locked office. The client has a right to access that chart and the material contained therein. You have no right to access the client’s chart without the written consent of the client. You will not have a diagnosis, and there is no individualized treatment plan for you.

Fees, Structure of Session, Cancellation Policy, and Emergencies
As a collateral, you are not responsible for paying for my professional services. The client is responsible for paying for my professional services. Sessions are typically 50 minutes in duration. If more time is needed they may be 75 minutes in duration which we will discuss prior to the appointment.

*In the event that you are unable to keep an appointment, you must notify me at least 24 hours in advance. Except in the case of emergency or sickness, if such notice is not received, the client or you will be financially responsible for the session you missed. Remember that texts, phones, and emails are not secure means of communication. Please use these options only to set or change appointments.*

If there is a clinical emergency and the client is unable to reach me at 423-894-3234. Please drive the client to the emergency room of your choice or call 911.
Confidentiality
The confidentiality of information in the client’s chart (PHI), including the information that you provide me, is protected by both federal and state law. It can only be released if the client specifically authorizes me to do so. There are some exceptions to this general rule:
1)If I suspect you are abusing or neglecting a child or a vulnerable adult, I am required to file a report with the appropriate agency. 2)If I believe that you are a danger to yourself (suicidal), I will take actions to protect your life even if I must reveal your identity to do so. 3)If you threaten serious bodily harm to another, I will take necessary actions to protect that person even if I must reveal your identity to do so. 4)If you, or the client, is involved in a lawsuit, and a court requires that I submit information or testify, I must comply. or 5)If the client signs a Release and directs me to talk to someone.
You are expected to maintain the confidentiality of the client in your role as a Collateral Participant.
Therapists are required to keep the identity of their clients and collateral participants confidential. In order to ensure your privacy, I will not address you in public unless you address me first. These guidelines are not meant to be discourteous. They are strictly for the client’s and your long-term protection.
Professional Relationship
Collateral Participants may discuss their own problems in therapy, especially problems that interact with issues of the identified client. If appropriate I may recommend formal therapy for a collateral participant. I will give you a list of three other clinicians and their contact phone numbers for treatment. It is important that you have your own therapist to guard against a dual relationship. Seeing two members of the same family, or close friends, may result in a dual role, and potentially cloud my judgment. Making a referral helps prevent this from happening. I must keep a focus on the original, primary task of working with the client. I am also limited to a professional relationship with the client and you to avoid dual relationships. I am unable to connect with you on Facebook, LinkedIn, Twitter, Instagram or any social media site.
Release of Information
The client is not required to sign an Authorization to Release Information to the collateral participant when a collateral participates in therapy. The presence of the collateral participant with the consent of the client is adequate. This provides assurance that full consent has been given to the clinician for the client’s confidential information to be discussed with the collateral in therapy.
However, an Authorization to Release Information from the client is helpful to the clinician when and if the collateral participant and the clinician communicate outside of session for one reason or another. In most instances the clinician cannot take a call from a collateral without an Authorization to Release Information form signed by the client.
Summary and Opportunity to Ask Questions
I sincerely hope this document has been helpful to explain your role in the client’s treatment, your rights, risks, and my procedures. If you have any questions about any part of this document, please ask.
Signature
Your signature below signifies that you understand the terms of this agreement and consent to follow these terms throughout our work together. Typing your name below serves as your signature and indicates your agreement to abide by the terms of this Collateral Participation Authorization and Informed Consent Document.
Please type your name below to sign.
Please indicate the date of your signature below.
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