Consent for Therapy (continued)
You can use these links to jump to any part of the Consent for Therapy:
   Clinical Overview
   Benefits and Risks of Treatment, Office Policies
   Confidentiality and Limits to Confidentiality, Complaints

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Confidentiality

The confidentiality of health information is protected by law. This includes information shared with a therapist. I am committed to maintaining this confidentiality in my practice. Information about you will only be released with your written permission through a signed and dated RELEASE OF INFORMATION, which clearly defines the nature of the information to be shared, with whom it will be shared and for how long. If the client is a minor, any release must be completed, signed and dated by a parent or legal guardian.

Limitations to Confidentiality

1. Texas State Law requires any therapist to notify legal authorities if you provide information indicating that you are abusing children, the elderly or if you express intent to harm yourself or another person or persons.
2. If a client reveals to the therapist any evidence of professional misconduct (e.g., sexual involvement) perpetrated by a previous clinical provider, the current therapist is required to report this information to the state licensing board for that clinician.
Failure of the treating therapist to report in either of the aforementioned circumstances is a breach of legal and ethical standards that can lead to prosecution and/or loss of licensure.

Complaints

Complaints against this therapist can be made by contacting:
The Texas State Board of Social Worker Examiners
1100 West 49thStreet
Austin, Texas 78756-3183
(800) 232-3162 or (512) 719-3521

Consent to Enter Therapy

I have read and fully understand the information provided in this document regarding the various services provided by this office and the potential risks and benefits of outpatient psychotherapy. I also understand the obligations and limitations of confidentiality within the context of the client/therapist relationship. I agree with the policies related to payment at the time of the service and cancellation of an appointment. I have had an opportunity to ask questions. I understand that I can leave therapy at any time and if I choose to do so will be assisted by the therapist in finding other clinical resources if any are desired. By signing this document, I acknowledge informed consent in my decision to seek outpatient psychotherapy with this therapist.

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