Name *
Date of Birth *
Date of Birth
Cell Phone *
Cell Phone
Pursuant to HIPPA (Health Insurance Portability and Accountability Act), a new federal law designed to provide you with privacy protections and patient rights with regard to disclosure of your Protected Health Information (PHI), our sessions and any communications between us will remain confidential. I will release information about our work together only with your written permission. The exceptions to this include: 1. In some court proceedings, a judge may order my testimony if they determine that the issues demand it. 2. If I believe that a patient is threatening serious bodily harm to themselves or another person, I will take protective actions, such as notifying appropriate individuals or hospitalization. 3. If I am aware that a child, elderly or otherwise vulnerable person is being abused, I am required to report this to the appropriate agency. 4. For clients that are minors, please be aware that by law, parents have the right to examine your treatment records. It is my policy to request parents agree to general information about our work together, unless I feel this would be a risk to your treatment. In any event, I will discuss information I intend to share with your parents prior to our conversation. From time to time, I may consult other professionals about therapy cases. During these conversations, I do not reveal the identity of a client. As they are also clinicians, they are bound by law to keep any information confidential as well. Confidentiality is an essential component of therapy, should you have any questions about the limits, please do not hesitate to ask. Type full name below with today's date: