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.
X_________________________________________________________
___/___/___
Signature
of
Client
Date
__________________________________________________________
___/___/___
rev20221029