Psychologist Confidentiality Agreement Form
Please review and acknowledge the confidentiality agreement below. This form is intended to formalize the understanding between psychologist and client regarding the privacy of shared information.
Psychologist's Name
*
First Name
Last Name
Client's Name
*
First Name
Last Name
Date of Agreement
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Psychologist's Email Address
example@example.com
Client's Email Address
example@example.com
Confidentiality Agreement Terms: All information shared between the psychologist and client during sessions will be treated as confidential and will not be disclosed to any third party except as required by circumstances mutually agreed upon by both parties. By signing below, both parties acknowledge and accept these terms.
Client's Signature
*
Psychologist's Signature
*
Submit Agreement
Submit Agreement
Should be Empty: