Confidentiality Agreement

This Confidentiality Agreement explains how your personal health information is handled, protected, and when it may be disclosed under federal (HIPAA) and state regulations.

1. Purpose

This agreement outlines how your personal health information is handled and protected during the course of our therapeutic relationship. It outlines your rights regarding privacy and the conditions under which your information may be disclosed.

2. Confidentiality of Sessions

All information disclosed during sessions is confidential. Your privacy is protected under the Health Insurance Portability and Accountability Act (HIPAA) and state laws. The information you share will not be disclosed to third parties without your written consent, except under specific circumstances outlined below.

3. Limits of Confidentiality

We may disclose your information without your consent only as required by law, such as:

• Risk of Harm: If you disclose intentions to harm yourself or others, the therapist may be required to take protective actions.

• Abuse: Reasonable suspicion of child, elder, or dependent adult abuse or neglect must be reported.

• Court Orders: We may be required to disclose records under a subpoena or court order.

4. Administrative Uses

Your health information may be used in compliance with HIPAA for treatment planning, billing and payment operations, and case management.

5. Electronic Communications

While we take reasonable steps to protect your data, electronic communication channels (e.g. email, text, telehealth) may not be fully secure. By signing, you acknowledge this risk and consent to electronic communication as needed.

6. Your Rights

As a client, you have the right to request access to your records and request restrictions on certain disclosures.

I consent to electronic communication via: (Select all that apply) * Required

EmailText messagePhone call/voice messages

Client Signature * Required

Signature

By signing this form, you confirm that you understand the information above and agree to the terms of confidentiality as outlined.

Confidentiality Agreement

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