Statement of Confidentiality & Agreement
STEP (Support Team for Educational Partnership)/Behavioral Health:
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 must breach confidentiality 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
3. When a court of police officer orders the release of certain information.
In the event that there will be a breach of confidentiality, the student will be notified.
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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This form was created inside of Building 21 Philadelphia.