Download Example Client Confidentiality Counseling Agreement for Free

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COUNSELING AGREEMENT
PLEASE READ AND SIGN THE FOLLOWING PRIOR TO SEEING Randall R. Lyle, Ph.D.
CONFIDENTIALITY
Confidentiality means that Dr. Lyle has a responsibility to safeguard information obtained during counseling.
All identifying information about your assessment and treatment is kept confidential, except as mandated by
law. You must sign a release of information before any information about you is given to anyone, except as
mandated by law.
In certain situations, mental health professionals are required by law to reveal information obtained during
therapy to other persons or agencies without your consent. In such situations, Dr. Lyle is not required to
inform you of his actions. Please note the following exceptions to confidentiality:
Confidentiality does not apply to cases of suspected abuse/neglect of children or the elderly.
Confidentiality does not apply to cases of potential harm to self or others.
A mental health professional may disclose confidential information in proceedings brought by a
client against a professional.
Confidentiality does not apply to cases involving criminal proceedings, except communications by a
person voluntarily involved in a substance abuse program.
Confidentiality may not apply in cases involving legal proceedings affecting the parent-child
relationship.
Confidentiality may not apply to cases involving a minor child. In such cases, the mental health
professional may advise a parent, managing conservator or guardian of a minor, with or without
minor’s consent, of the treatment needed by or given to the minor.
Insurance and managed care companies require personal identification information, diagnosis, symptoms,
treatment goals, prognosis, evaluation of progress, and other information before reimbursement is
considered. Such companies may also maintain the right to have a copy of your records.
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPPA)
Dr. Lyle is required by law to protect the privacy of your health information. Although your counseling
record is the physical property of Dr. Lyle the information contained in your health record belongs to you.
You have the right to:
request a restriction on certain uses and disclosures of your information
inspect and obtain a copy of your health record
amend your health record as provided by regulation
obtain an accounting of disclosures of your health information as provided by law
request communications of your health care information by alternative means or locations
revoke your authorization to use or disclose health information except to the extent that action has
already been taken
THE BENEFITS OF COUNSELING
One major benefit that may be gained from participating in counseling is the resolution of the concerns
brought to therapy. Other possible benefits may be a better ability to cope with marital, family and other
interpersonal relationships, and /or a greater understanding of personal goals and values.
THE RISKS OF COUSNELING
There are certain risks involved in counseling. You may experience a variety of negative emotions during
therapy as you remember and therapeutically resolve unpleasant events. Seeking to resolve concerns
between family members, marital partners, and other persons can similarly lead to discomfort as well as
relationship changes that may not be originally intended. The greatest risk of counseling is that it may not by
itself resolve your concerns. Dr. Lyle will do his best to assess progress and provide referral to other sources
if that is deemed necessary and appropriate. Psychotherapy is a collaborative process and the progress you
make will depend in large measure upon your investment in the process.
Example Client Confidentiality Counseling Agreement
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