Counselors Without Borders

Confidentiality Form

Counseling Sessions and Process

To maintain quality assurance standards, counseling sessions are recorded unless otherwise requested. To ensure accountability standards and monitor progress, written records of session work are maintained on an on–going basis. Recordings and written records could be subpoenaed by a court of law under certain circumstances.

All information related to the counseling/consulting relationship is treated as strictly confidential and may be shared with only with the written permission of the person receiving service
Exceptions Include:
 

    Reporting of suspected child abuse or neglect
    Complying with requirements of an investigation  
    Responding to a medical emergency
    Complying with a court ordered subpoena
    Responding to a threat of harm to self and/or others

I understand the above and consent to being an active participant in receiving services:
First Name *
Last Name *
Email Address *
Telephone Number