Confidentiality and Consent to Participate in Treatment

The confidentiality of all records maintained by Jared Golant is protected by federal and state law and regulations.  Generally, Jared Golant may not say to a person outside of the practice that a client is seeking services with Jared Golant, or disclose any information that identifies you as a client unless:

1.       The client consents in writing;

2.       The disclosure is allowed by a court order; or

3.       The disclosure is made to medical personnel in a medical emergency to qualified personnel 

4.       You (the client) presents an immediate danger to harm self or other(s)

5.       Federal laws and regulations do not protect any information about suspected child/elder abuse or neglect from 

       being reported under State law to appropriate state or local authorities.

Emergency Contact – Your counselor cannot assume responsibility for your day to day functioning, as can be done in inpatient institutions.  It is the responsibility of the client to discuss expectations of after hours care with the counselor upon intake, so that if necessary an appropriate referral can be made.  In the event of an emergency, when a client is fearing harm to himself/herself or others, he/she should call the 24 hour crisis hotline in the county in which they live or if necessary go to the nearest hospital emergency room.  Your counselor will contact you as soon as he or she is made aware of the crisis situation.  

I, ________________________________(please print), have received and understand the above notice concerning my confidentiality rights and consent to treatment with Jared Golant.  I agree and authorize on a voluntary basis for Jared Golant to provide me with treatment, as deemed necessary.

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         Signature of Client                                                                                                                                  Date

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