Agreement

As we began our work together, I would like to emphasize my understanding that your health care information is personal and I will be committed to protecting your health care information during the course of treatment. It is therefore important to clarify the confidential nature of the therapeutic relationship. All information between therapist and client is held strictly confidential and may not be disclosed without your written permission. There are several exceptions to this rule, that by law may require for me to disclosed your health care information. The following exceptions describe different ways that I may need to disclose information shared in the therapeutic relationship:

• Should a client disclose to me any suspected child abuse, current or past, of a minor child, I am required by law (Section 11161.5 of the California Penal Code) to report this to the Department of Children and Family Services.
• Should a client disclose to me any suspected elder/dependent adult abuse, I am required by law to report this to Adult Protective Services.
• If I believe that a client truly intends to harm him/herself, I will first make every effort to enlist the client’s cooperation in ensuring his/her safety. If I am unable to do this, by law I may need to take further measures to insure the client’s safety without the client’s permission.
• If I believe that a client actually intends to do physical harm to someone else, I must notify the police and the intended victim.
• I appreciate your understanding and acceptance of my legal responsibility in the above situations and I would like to assure you that every effort is made to handle your treatment in a sensitive and caring manner. If you have any questions or concerns, please discuss them with me.