Statement of Confidentiality & Agreement

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All services are personal and confidential. The information shared with us will only be discussed within
the Behavioral Health Department, unless consent is given by student to share confidential information
with other individuals or parties. Below are circumstances in which confidentiality information can be breach without the student’s consent:

1. To protect the student or someone else when the student intends to carry out violent, harmful,
or dangerous actions.
2. To protect the student when they themselves are victims of violent, harmful, or dangerous
actions.
3. When a subpoena is issued .

In the event that there will be a breach of confidentiality, the student and parent/guardian will be notified.

Email *

Record my email address with my response

Agreement *

By checking this box, I acknowledge that I understand that the information I am providing is confidential and will remain so, unless on of the above mentioned circumstances occurs.

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