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.