A therapist is legally prohibited from disclosing any information about a client without that client’s explicit permission. The only exceptions are the therapist believes that the client is a danger to him/herself or to others, or if the therapist has a reasonable suspicion of abuse of a child under 18 years old or a vulnerable adult.
Please see the full notice of privacy practices here.
If you’re a new client, you will need to fill out and sign the following forms. Please do not fill them out until you have been instructed to do so. You can fill them out in any of the following ways:
- Download them here, fill them out, and bring them to the office
- Download them, fill them out (digitally or by hand), scan, and send them back to firstname.lastname@example.org.
Please note that e-mail is not a perfectly confidential means of communication. There is a chance that these files could be exposed to unknown third parties on the Internet. They may also be exposed to people in your home or, if you are using your work e-mail, your employer. Please take these facts into consideration before choosing this option. See Consent to Treatment form for more information.
- Fill them out by hand in the office.
To read before signing:
To fill out and sign:
The following forms do not need to be filled out unless you are specifically asked to do so by your therapist:
In order for me to communicate with other relevant parties (for example, your psychiatrist, primary care physician, school guidance counselor, etc.), I will need you to complete and sign this form to authorize me to release your/your child’s information:
- Authorization for Release of Confidential Information
- Authorization for Release of Confidential Information of a Minor
Note: To download Adobe Acrobat Reader for free, click here.