Informed Consent And Limits Of Confidentiality
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1Community Counseling
Informed Consent and Limits of Confidentiality
Limits of Confidentiality:
The contents of a counseling, intake or assessment session are considered to be confidential. Both verbal information and written records about a
client cannot be shared with another party without the written consent of the client. It is the policy of the Community Counseling Center not to
release any information about a client without a signed release of information. Noted exceptions are as follows:
-
Duty to Warn and Protect:
o
When a client discloses intentions or a plan to harm another person, the health care professional is required to warn the
intended victim and report this information to legal authorities. In cases in which the client discloses or implies a plan for
suicide, the health care professional is required to comply with Chapter 394, Florida Statues (The Baker Act) by notifying legal
authorities when a client will not voluntarily consent to emergency treatment.
-
Abuse of Children and Vulnerable Adults:
o
If a client states or suggests that he or she is abusing a child (or vulnerable adult) or is in danger of abuse, the health care
professional is required to report this information to the appropriate social service and/or legal authorities.
-
Court Orders:
o
clients when a court order has been served.
Health care professionals are required to release records to
Informed Consent (please check boxes):
I consent to receive services from The Community Counseling Center of Empath Health.
I understand that this program does not provide emergency services and I have been provided with a referral resource list that I may call
in an emergency or on weekends/evenings.
I understand that my case will be closed after 30 days of inactivity or 3 consecutive “missed appointments”.
I understand that if I cannot attend a scheduled appointment time, I need to cancel within 24 hours.
I have been informed and understand the limits of client confidentiality.
Emergency Contact
I understand that I must provide an
person while I am a client of The Community Counseling Center. I authorize the staff of The
Community Counseling Center to contact:
Emergency Contact Name
Relationship
: _________________________________________________
:
_________________________________________
Home Phone: ______________________________________ Cell Phone: ________________________________ Work Phone: ________________________________
Client Signature:
_________________________________________________________
Date: ________/_____/20_____
Client Printed Name: ____________________________________________
Counselor Signature / Credentials:
___________________________________
Date: _____/_____/20_____
MINOR CONSENT:
FOR EACH PARTICIPATING MINOR - PLEASE READ THE FOLLOWING STATEMENTS:
1.
CHECK ALL STATEMENTS YOU ARE IN AGREEMENT WITH and 2. SIGN AND DATE ON BELOW
I understand that my child(rens) participation in the Community Counseling Center counseling is voluntary. I may discontinue any or all services upon
request.
I give my permission for my child(ren) to participate in counseling provided by the Community Counseling Center.
I understand that all information will be held in confidence unless a Release of Information form is requested and signed by the parent/guardian.
I understand that information collected during treatment may be used for research purposes.
Names of Participating Children:
________________________________________________
#_____________________
________________________________________________
# _____________________
________________________________________________
# _____________________
_____________________________________________
Parent/Guardian Signature:
Date: ______/_______/20_______
Parent/Guardian Printed Name:_____________________________________________________
_______
Counselor Signature / Credentials:
___________________________________
Date: _____/_____/20_____
OFFICE USE ONLY:
Client # ___________________________
Client: Last ________________________________________ First: _____________________________
Admit Date: ______/______/20_______
Scanned
Audited: _______/________/20__________
C:\Users\candyle\Desktop\Community Counseling Consent Forms\REVISED CONSENT UNIVERSAL June 2015.docx
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