* Please note: Email correspondence is not considered to be a confidential medium of communication.
In the section below, identify if there is a family history of any of the following. If yes, please indicate the family member’s relationship to you in the space provided (e.g. father, grandmother, uncle, etc.)
Limit of Services and Assumption of Risks
Therapy sessions carry both benefits and risks. Therapy sessions can significantly reduce the amount of distress someone is feeling, improve relationships, and/or resolve other specific issues. However, these improvements and any “cures” cannot be guaranteed for any condition due to the many variables that affect these therapy sessions. Experiencing uncomfortable feelings, discussing unpleasant situations and /or aspects of your life are considered risks of therapy sessions.
Limits of Confidentiality
What you discuss during your therapy session is kept confidential. No contents of the therapy sessions, whether verbal or written may be shared with another party without your written consent or the written consent of your legal guardian. The following is a list of exceptions:
Duty of Warn and Protect
If you disclose a plan or threat to harm yourself, the therapist must attempt to notify your family and notify legal authorities. In addition, if you disclose a plan to threat or to harm another person, the therapist is required to warn the possible victim and notify legal authorities.
Abuse of Children and Vulnerable Adults
If you disclose, or it is suspected, that there is abuse or harmful neglect of children or vulnerable adults (i.e. the elderly, disabled/incompetent), the therapist must report this information to the appropriate state agency and/or legal authorities.
History of Child Abuse in Maryland
If you disclose that you were abused as a child in the State of Maryland, and you identify your abuser, the therapist must report this to Child Protective Services, even if your abuser is deceased.
Prenatal Exposure to Controlled Substances
Therapists must report any admitted prenatal exposure to controlled substances that could be harmful to the mother or the child.
Minors/Guardianship
Parents or legal guardians of non-emancipated minor clients have the rights to access the clients’ records.
By signing below, I agree to the above assumption of risk and limits of confidentiality and understand their meanings and ramifications.
