As you know, I am providing services to a client, who has authorized me to share information with you and to obtain information from you. You are a “collateral” in the treatment process. By definition, a collateral is a person who is not a client but who may attend a session with the client, or who may confer with a therapist at the request of and with the consent of the client.

By signing this disclosure you acknowledge that you are not my client, and you will not be receiving treatment or services from me. If you would like to receive counseling from a mental health professional, please let me know, and I will provide you with appropriate therapy referrals. Any treatment information which I share with you is confidential, you may not share that information with anyone else.

Any information that you share with me will be confidential, as part of my client’s treatment record, and I may share that information with my client. The confidentiality or therapist-client privilege relating to information provided to a therapist by a collateral belongs to the client, not the collateral. Additionally, there are several exceptions or limits to confidentiality, which include:

Situations of suspected or confirmed child abuse or neglect;
Abuse or exploitation of an at-risk adult or elder, including imminent risk of such abuse;
Threats of harm to others, including people identifiable by their association with a specific location or entity;
Threats of harm to yourself.
Any suspected threat to national security will be reported to federal officials.

In such situations, I may be required to take protective actions which may include notifying the potential victim, contacting the police, or seeking hospitalization for the client. If such a situation arises during our work together, I will make every attempt to discuss it fully with you before taking necessary action.

In addition, I may disclose confidential information in the course of consultation with other professionals.  I will make every effort to avoid revealing your identity in the course of such consultation, and any professional with whom I consult will be legally bound to keep the information confidential.  

Signing this document gives me permission to consult as necessary.  I may also reveal confidential information in the event of an investigation of a complaint or civil suit filed against me or if I am ordered to do so by a court of law.  There may be other exceptions to confidentiality as provided by HIPAA regulations and other Federal and/or Colorado laws and regulations that may apply.