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Agreement for Confidentiality of Individual Treatment

I understand that it is Dr. Smith’s role to provide therapeutic services so that I might feel better and/or improve my functioning, especially as it relates to my family. Dr. Smith’s role is not intended to gather information for the courts or to make judgments related to my family.

Therefore, I agree that I will not call upon Dr. Smith to provide treatment records or to testify in a future divorce or custody action. I understand that courts can appoint professionals who have had no prior contact with my family to conduct independent evaluations and make recommendations to the court.

I understand that it is Dr. Smith’s policy to have no court involvement in my case because that could harm our professional relationship and the ability to achieve my goals. My goals include resolving personal concerns so that I might preserve my marriage and/or be a better parent. Since I need to speak freely, my spouse is also agreeing never to ask Dr. Smith to testify or have his records of my treatment in court.

By signing this form we are both agreeing not to use any of my therapeutic intervention records or testimony in any future court proceedings.

Signed: ___________________________________________________Date________________

Signed: ___________________________________________________Date________________

……………………………….
*In contrast to the confidentiality (“non-subpoena”) contract for multi-client therapy
(e.g., couples therapy or family therapy), which is signed only by participating parties,
this form requests the signature of the non-participating spouse, agreeing not to use information from the spouse’s individual therapy as evidence in a court case.
This is not a legally binding contract,
but the spouse’s signature on this agreement reduces the likelihood
that the therapist will be subpoenaed in any later legal proceeding.

This sample form was provided by Thomas DeMaio, Ph.D.,
Clinical Psychologist in Charlottesville, Virginia.

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continuing education for American Psychological Association The Center for Ethical Practice is approved by the American Psychological Association (APA) to sponsor continuing education for psychologists. The Center maintains responsibility for this program and its content.


continuing education for National Board for Certified Counselors (NBCC) The Center for Ethical Practice has been approved by National Board for Certified Counselors (NBCC) as an Approved Continuing Education Provider (ACEP No. 6768). The Center is solely responsible for all aspects of the programs. Programs that do not qualify for NBCC credit are clearly identified.


continuing education Association of Social Work BoardsThe Center for Ethical Practice (provider #1287), is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved as ACE providers. State and provincial regulatory boards have the final authority to determine whether an individual course may be accepted for continuing education credit. The Center for Ethical Practice maintains responsibility for this course. ACE provider approval period: 3/21/2021-3/21/2024.

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