Confidentiality Agreement

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You are entitled to a confidential relationship with me. It is one of your most important

rights in the counseling situation. You should know that in certain situations I am

required by law to reveal information obtained during therapy to other persons or

agencies. I may do this without your permission. These situations are as follows: a) if

you threaten grave bodily harm or death to another person, I am required by law to

inform the intended victim and appropriate law enforcement agencies; b) if you mention

instances of child or dependent adult abuse to me I am required to report such instances

to proper authorities; c) if a court of law (not an attorney) issues a legitimate subpoena, I

have to provide the information specifically described in the subpoena. In addition, I

may choose to breach confidentiality if you are gravely dangerous to yourself. If you are

utilizing your insurance benefits, I will need to share pertinent private health information

in order to obtain visits to complete your treatment and payment for the treatment. I may

or may not acknowledge your participation in therapy to the referral source. Make sure

you discuss any questions you have about confidentiality and related issues with me.

You have a right to review your records. You have a right to restrict the use/disclosure of

your health information. You have a right to file a complaint with the Board of Marriage

and Family Therapy.

To insure maximum benefits from therapy, it is very important that you make every effort

to come to your scheduled appointments. In the event that you must cancel an

appointment, please call 24 hours in advance. You will be charged for a full therapy

hour for appointments that are not cancelled 24 hours in advance.

The fee will be due on the same day that you see me. A retainer of $100 will be

collected at your first appointment and held in your file. If at the completion of

your therapy there are no missed appointments or any balance, the retainer fee will

be returned to you. Following a missed appointment, an additional $100 retainer

fee will again be collected.