Request for Services & Confidentiality Agreement
Your right to confidentiality is mandated by my licensing bodies and professional ethics. Unless you grant me permission to do so in writing, I will maintain all correspondence as confidential and privileged communication. Please note that any records will be destroyed after 10 years. There may be circumstances in which I as a licensed professional have a legal obligation to disclose information without your written permission:

Harm to a Child/Elderly Person/the Disabled: If I am made aware that a vulnerable person is in direct danger, I am legally obligated to make my concerns known to the appropriate authorities.

Harm to Self or Others: If at any time it is my clinical assessment that your actions or intentions are of a threatening nature to yourself or others I have a legal obligation to make these concerns known to the appropriate authorities.

Order of the Court. There are times when a court of law may request information regarding your treatment where it is applicable to legal proceedings involving yourself. It is customary to refuse to provide content or redact content to the furthest extent possible.

Professional Supervision. At times I will seek the advice of clinical supervisors or in peer consultation as best practice recommends. These persons will also be held to the guidelines of strict confidentiality and privileged communication.

By submitting this form and entering your email address below, you indicate that you are fully informed and agree to the preceding information and consent to services. You also agree that if you or someone in services with you makes an allegation against this professional for a legal or ethical violation I have the right to release information sufficient to my own defense against the allegations made.

I am collecting your preferred emails for my newsletter, and I encourage you to read them as I post updates to services and relevant content in those emails. You can unsubscribe from the newsletter at any time. No identifying information will be published or shared.

Dr. Taylor Burrowes Email: contact@drtaylorburrowes.com Website: www.drtaylorburrowes.com

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