Counseling Confidentiality Agreement Form
Please review and acknowledge the terms of confidentiality for counseling sessions.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Counselor's Name
First Name
Last Name
Date of Session
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Confidentiality Agreement
*
Please indicate your relationship to the counseling session
*
Client
Parent/Guardian
Other
Preferred Method of Contact for Confidential Matters
Please Select
Email
Phone Call
Text Message
Signature (Please sign to acknowledge your agreement)
*
Submit
Submit
Should be Empty: