Celebration Counseling

Confidentiality Statement

In general, the confidentiality of all communications between a client and a psychologist is protected by law, and I can only release information about our work to others with your written permission. However, there are a number of exceptions.

In most judicial proceedings, you have the right to prevent me from providing any information about your treatment. However, in some circumstances such as child custody proceedings and proceedings in which your emotional condition is an important element, a judge may require my testimony if he/she determines that resolution of the issues before him/her demands it.

1. If I believe that a client is threatening serious bodily harm to another, I am required to take protective actions, which may include notifying the potential victim, notifying the police, or seeking appropriate hospitalization. If a client threatens to harm himself/herself, I may be required to seek hospitalization for the client, or to contact family members or others who can help provide protection.

2. If I believe that a child, an elderly person, or a disabled person is being abused, I must file a report with the appropriate state agency.

3. If I assess the patient to be a danger to self, or unable to take care of himself/herself, I may notify appropriate authorities.

4. In the event of failure to pay a bill in reasonable time, the name of the patient may be given to a collection agency to collect payment or may be recorded in small claims court.

5. Some legal actions initiated by the patient or the patient's estate may result in the court ordering the release of records.

6. Records and information regarding your diagnosis and treatment must be submitted to your insurance carrier for determination of benefits and authorization for continued treatment.

Client Name: _____________________________________________________________

Client Signature: __________________________________________________________

Date: ______________________________________

Witness Date: _______________________________