Hospice East Bay Confidentiality & Consent Agreement/ADULT 02-19-21

Confidentiality Agreement/Consent for services - ADULT
CONFIDENTIALITY AGREMENT
I (the client) will respect the confidentiality of all information shared/obtained while participating in emotional support services. I also expect that the information I provide will be held in strict confidence by the Counselor and support group participants, if applicable. I understand a counselor may discuss the client with a clinical supervisor or clinical team.
I understand that in all other circumstances, the client must sign a release of information form in order to give permission to reveal that I am receiving emotional support counseling and to discuss issues involving my treatment with any other person or agency.
Information shared by the client during phone conversations and support sessions will be held in confidence except in situations when mandated reporting is required:
- When the client threatens bodily injury to another or is suicidal.
- When there is reasonable suspicion that abuse or neglect toward a child, elder or dependent adult has or will occur.
- When ordered by a court.
CONSENT FOR SERVICES
By signing this form, I consent to the terms outlined herein and agree to recieve support services that may include one-on-one emotional support, group support, assessment and/or referral by a Hospice East Bay Counselor.
Client Name
First NameLast Name
Phone Number
Area CodePhone Number
Email
example@example.com
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Emergency Contact Name
First NameLast Name
Emergency Contact Phone Number
Area CodePhone Number
Emergency Contact Email
example@example.com
Client Signature
Clear
Date Signed
MonthDayYear
Date
Should be Empty:

Confidentiality Agreement/Consent for services - ADULT