Confidentiality Form

Fill out the Confidentiality Form below and submit it to our office once fully complete. If you would rather print a copy of the form, fill it out, and bring it to the office, you can click the button below to download a copy of this form.

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Communication between a patient and his or her psychologist is confidential, and we are bound by law and ethics to safeguard your personal health information. The psychologist may use your information as necessary for treatment and/or evaluation, billing, and healthcare operations involving your care.

  • If you are using health insurance to pay for your care, you have already given your permission to the insurance company to access information necessary to process claims and oversee services provided.
  • Otherwise, your written permission is necessary to release any information about you to anyone outside the practice, with some exceptions as noted below:

Some state laws specify certain circumstances when a mental health professional may be required to break confidentiality. Please bear in mind that every effort will be made, as clinically appropriate, to discuss and/or resolve any issues before such a breach of confidentiality takes place, should the occasion ever arise. Breaking confidentiality is required under the following circumstances:

  • If an individual intends to take harmful or dangerous action against another individual, it is the health care professional’s duty to warn the person and/or family of the person who is likely to suffer the results of the harmful behavior, as well as the local authorities, in order to protect the individual and any potential victim(s).
  • If an individual poses a danger to himself or herself, health care professionals are required to disclose information for the purpose of keeping the individual safe and facilitating appropriate treatment.
  • Suspicion of child abuse or neglect.
  • Information regarding certain forms of sexual contact between children under the age of 16.
  • Suspicion of the abuse of elders or handicapped persons.
  • In response to a court order by a judge.
  • If a patient introduces his or her mental condition as an element of claim or defense in a legal proceeding.
  • Court investigations into child custody or adoption.
  • Workers’ compensation claims.
  • Government oversight activities such as Boards of Registration proceedings; the Department of Health and Human Services, and national security agency requests.

Confidentiality as it applies to minor children: In the case of minor children, the law may allow parents the right to examine treatment or evaluation records. Though you will be asked to be involved in and informed about your child’s progress, release of specific communications often can jeopardize a child or adolescent’s willingness to be forthcoming with her/his doctor or therapist. In order to both respect the confidential nature of your child’s information and facilitate the building of trust, your child’s doctor or therapist will ask you to agree to certain limits on the information that will be shared with you. Of course, if there are any concerns about potential dangerousness, you will be notified immediately.

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