I understand that the purpose of my attending is to assist the client and the therapist in the client's treatment and not to seek psychotherapy for myself.
I understand that my role as a collateral ally in the client's psychotherapy is to provide information about the client, both factual and from my personal perspective. I understand that my participation is voluntary, and that at any time I can withdraw and/or decline to answer any question. I understand that this experience may generate positive feelings by creating better understanding, but it can also create anxiety or distress.
I certify that I do not have a personal or client relationship with this therapist.
I understand that I am not responsible for any therapy fees unless I am financially responsible for this client.
I understand that what I say in session(s) may be discussed between the therapist and the client. I understand that no record will be maintained on me in my role as a collateral. However, I also understand that notes about me may be entered into the client’s chart. I understand that the client has a right to access the chart and the material contained therein. I have no right to access the chart without the written consent of the client.
I will not be given a diagnosis and there will be no individualized treatment plan for me. As a collateral ally I understand that I have certain rights and requirements pertaining to confidentiality, as well as some limits to that confidentiality. I am expected to maintain the confidentiality of the client. The confidentiality of information in the client’s chart, including information that I provide, is protected by both federal and state law and can only be released if the client specifically authorizes the therapist to do so.
