Any information you discuss in therapy is classified as “private” under Minnesota law and will be used to help assess your problem, to determine counseling goals and to provide the services you need. State statutes and ethical standards for psychologists require that relevant information be released if any of the following events or circumstances occur. All therapists are mandated reporters.
Whereas records are subpoenaed by the courts.
It there is suspicion of neglect or abuse of a child or vulnerable adult
If there is potential for suicide, homicide or threat of imminent serious harm to another Individual
If Client identifies a psychologist or another counseling professional and discloses that he or she has had sexual contact with a client throughout the term of therapy or within two years of the termination of therapy, we are ethically required to report to the Minnesota Board of Marriage and Family Therapy, and the Minnesota Board of Social Work.
If Client is a minor, parents have access to records. Minor clients can request, in writing, that particular information not be disclosed to parents. Such a request should be discussed with the therapist.
If Client is involved in more than one mode of counseling or therapy at Family Revelations Inc. For example…group, individual, marriage, family, etc…those providing care are allowed to consult with, to, cooperate with and mutually share information to the extent needed to serve the best interests of their clients.
Whereas in regularly scheduled supervision meetings at Family Revelations Inc, and where appropriate outside professional consultation is needed, those providing care are allowed to consult with, refer to, cooperate with and mutually share information to the extent needed to serve the best interest of their clients. Added supervisory or consultation requirements may be needed by students, trainees, graduate-interns, volunteers, or in other special circumstances where deemed appropriate. Client information is discussed, although efforts are made to protect client’s individually identifiable information.
Most insurance companies have a co-payment and/or annual deductible which is your responsibility to pay at the time of each session. Client authorizes this provider (Family Revelations, Inc.) to release any information necessary to process insurance claims. By doing so the client authorizes payment of medical benefits to this provider (Family Revelations, Inc.) for mental health services. Family Revelations Inc. cannot guarantee confidentiality of records held by insurance companies
I have received and understand the Patient Bill of Rights.
My signature below indicates that I understand and consent to the above disclosures.