Confidentiality agreement template

-By Timothy Lyons

There are many cases that an agreement between a therapist and a client have information about confidentiality. At the end of this page a confidentiality agreement template will be provided. The form which is normally considered to be an informed consent form may have far more information than just on confidentiality.

Purpose

The purpose of a confidentiality agreement, which will be presented in the confidentiality agreement template is to enhance the therapeutic relationship. This is done by allowing the client to understand the boundaries of information that they may comfortably speak of in therapy.

As long as none of the factors that are outlined in the confidentiality agreement template take place, confidentiality will be maintained. A level of comfort can be gained by the client with these assurances. This is also a tool by which the therapist allows the client to discuss anything that may be confusing and ask questions.

Without a doubt, one of the cornerstones of any therapy is that the client must know that what they discuss in the sessions will not be passed on. Counseling involves sharing personal, private and sensitive information. In order for the client to feel less anxious and stressed about sharing this information, they should know just what is confidential and what is not. This is the information that will be in the confidentiality agreement template.

This confidentiality agreement would normally be a portion of a larger agreement which is known as an informed consent form. In some circumstances, a therapist might want to have separate forms to address the different issues that make up the informed consent form. This may allow a better understanding by the client in each of the areas that might come up. In this case, I will provide the confidentiality agreement template. It will be just that portion which addresses just those limits and nothing else. Feel free to copy this attachment and use it for your own purposes in creating your own version of an informed consent document.

Confidentiality agreement template

Confidentiality

All interactions which take place in the setting of therapy are considered confidential. This includes requests by telephone, all interactions with this counselor, any scheduling or appointment notes, all session content records and any progress notes that I take during your sessions. I will not even verify that you are a client. You may choose to give me permission in writing to release any or specific information about you to any person or agency that you designate.

Limits to this agreement

1. In some legal proceedings a judge may issue a court order. This would require this counselor to testify in court.
2. If I learn of or believe that there is physical or sexual abuse or neglect of any person under 18 years of age, I must report this information to county child protection services.
3. If I learn of or believe that an elderly person, or disabled person is being abused or neglected, I must file a report with the appropriate state agency that handles elder abuse.
4. If I learn of or believe that you are threatening serious harm to another person, I am obligated to report this. This can be in the form of telling the person who you have threatened, contacting the police or placing you into hospitalization.
5. If there is evidence that you are a danger to yourself and I believe that you are likely to kill yourself unless protective measure are taken, I may be obligated to seek hospitalization for you or to contact family members or others who can help provide protection
6. There may be times when I consult with outside sources about cases. In these cases, no personally identifiable information will be used to discuss this case. However, discussion topics will be used in order to ensure that I am getting and giving the best assistance possible. The persons with whom I discuss cases are legally bound to keep information confidential.

I have read and discussed the above information with my therapist. I understand the nature and limits of confidentiality.

______________________________       ___________________

Client signature                                             Date