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Confidentiality and it’s Limits in My Practice

(Sample* Handout to Explain to Clients Your Policies About Confidentiality and Its Limits)



As a rule, I will disclose no information about you, or the fact that you are my patient, without your written consent. My formal Mental Health Record describes the services provided to you and contains the dates of our sessions, your diagnosis, functional status, symptoms, prognosis and progress, and any psychological testing reports. Health care providers are legally allowed to use or disclose records or information for treatment, payment, and health care operations purposes. However, I do not routinely disclose information in such circumstances, so I will require your permission in advance, either through your consent at the onset of our relationship (by signing the attached general consent form), or through your written authorization at the time the need for disclosure arises. You may revoke your permission, in writing, at any time, by contacting me.

There are some important exceptions to this rule of confidentiality – some exceptions created voluntarily by my own choice, and some required by law. I will also highlight situations where confidentiality is potentially, though not necessarily, at risk. If you wish to receive mental health services from me, you must sign this Agreement indicating that you understand and accept my policies about confidentiality and its limits.

· Emergency: If you are involved in a life-threatening emergency and I cannot ask your permission, I will share information if I believe you would have wanted me to do so, or if I believe it will be helpful to you.

· Child Abuse Reporting: If I have reason to suspect that a child is abused or neglected, I am required by Virginia law to report the matter immediately to the Virginia Department of Social Services.

· Adult Abuse Reporting: If I have reason to suspect that an elderly or incapacitated adult is abused, neglected or exploited, I am required by Virginia law to immediately make a report and provide relevant information to the Virginia Department of Welfare or Social Services.

· Health Oversight: Virginia law requires that licensed psychologists report misconduct by a health care provider of their own profession. By policy, I also reserve the right to report misconduct by health care providers of other professions. By law, if you describe unprofessional conduct by another mental health provider of any profession, I am required to explain to you how to make such a report. If you are yourself a health care provider, I am required by law to report to your licensing board that you are in treatment with me if I believe your condition places the public at risk. Virginia Licensing Boards have the power, when necessary, to subpoena relevant records in investigating a complaint of provider incompetence or misconduct.

· Court Proceedings: If you are involved in a court preceding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law, and I will not release information unless you provide written authorization or a judge issues a court order. If I receive a subpoena for records or testimony, I will notify you so you can file a motion to quash (block) the subpoena. However, while awaiting the judge’s decision, I am required to place said records in a sealed envelope and provide them to the Clerk of Court. In civil court cases, therapy information is not protected by patient-therapist privilege in child abuse cases, in cases in which your mental health is an issue, or in any case in which the judge deems the information to be “necessary for the proper administration of justice.” In criminal cases, Virginia has no statute granting therapist-patient privilege, although records can sometimes be protected on another basis. Protections of privilege may not apply if I do an evaluation for a third party or where the evaluation is court- ordered. You will be informed in advance if this is the case.

· Serious Threat to Health or Safety: Under Virginia law, if I am engaged in my professional duties and you communicate to me a specific and immediate threat to cause serious bodily injury or death, to an identified or to an identifiable person, and I believe you have the intent and ability to carry out that threat immediately or imminently, I am legally required to take steps to protect third parties. These precautions may include 1) warning the potential victim(s), or the parent or guardian of the potential victim(s), if under 18, 2) notifying a law enforcement officer, or 3) seeking your hospitalization. By my own policy, I may also use and disclose medical information about you when necessary to prevent an immediate, serious threat to your own health and safety. If you become a party in a civil commitment hearing, I can be required to provide your records to the magistrate, your attorney or guardian ad litem, a CSB evaluator, or law enforcement officer, whether you are a minor or an adult.

· Workers Compensation: If you file a worker’s compensation claim, I am required by law, upon request, to submit your relevant mental health information to you, your employer, the insurer, or a certified rehabilitation provider.

· Records of Minors: Virginia has a number of laws that limit the confidentiality of the records of minors. For example, parents, regardless of custody, may not be denied access to their child’s records; and CSB evaluators in civil commitment cases have legal access to therapy records without notification or consent of parents or child. Other circumstances may also apply, and we will discuss these in detail if I provide services to minors.

· Collections: Information regarding your involvement in treatment (i.e. dates of treatment and billing record) may be released in the event that legal collection action becomes necessary by my office.

· Insurance: Information regarding your treatment, dates of services, diagnosis and treatment plans (and, in rare cases, the entire record) will be released to your insurance company if you choose to have my office file your insurance claims.

· Complaints: If you file a complaint or lawsuit against me, I may disclose relevant information regarding your treatment in order to defend myself.

· Billing, Insurance Filing, and Payment: I contract with a billing service to file insurance claims on your behalf, to manage collection of fees, to assist with insurance authorizations, and to provide payment receipts to you. This service does not have access to your treatment record and they are required to maintain the confidentiality of the data I provide for the billing services. Further, if you pay with a personal check, be aware that bank tellers may become aware that you are a client at my office when I make deposits to my business account.

· Electronic Transmission: I will, at times, share personal information about you with the billing service, insurance companies, or other entities with whom you authorize me to share information via electronic transmission, including fax machines, e-mail, or cellular telephones. Despite my efforts, these transmissions cannot be guaranteed to be secure.

· Consultation: At times I will consult with professional colleagues about aspects of your case. Your name and unique identifying characteristics will not be disclosed. The consultant is also legally bound to keep the information confidential.

While this written summary of exceptions to confidentiality should prove helpful in informing you about potential issues, it is important that we discuss any questions or concerns you may have now or at any time in the future. I will be happy to discuss these issues with you if you need specific advice, but formal legal advice may be needed because the laws governing confidentiality are quite complex, and I am not an attorney. If you request, I will provide you with relevant portions or summaries of the state laws regarding these issues.


By signing below, you are indicating that you have been informed about these policies and have been given the opportunity to ask questions about them, that you understand them, and that you consent to accept them as a condition of receiving therapy services.

Patient Signature: _________________________________________________


*This is a sample form only.

If adopting it, be sure to “personalize” it to reflect actual policies in your own setting

about confidentiality and disclosure .