Patient Intake Form

Confidentiality Statement

What we discuss in therapy is confidential. This means that what you say will not be talked about with anyone else. There are, however, four exceptions to this, which are: 1) If you are in danger to yourself (suicidal), or 2) If you are a danger to others. In these first two cases it is mandated by law that I take steps to ensure your safety and the safety of others. 3) If you disclose the identity of a minor who has ever been abused physically, sexually, or mentally, I am legally bound to disclose this information to the Department of Family and Child Services (DFACS), and 4) If you are involved in a legal matter, I may be required to comply with the demands of the court. This may entail releases treatment records to the court

Download the form & send it to [email protected]