This Confidentiality Agreement (the “Agreement”) is made between the therapist, Jasmine W, practicing at Eliora, 2C/1, Fort Station Road, Main Guard Gate, Trichy – 620002, and the client, ________________, residing at _________________Together, the therapist and the client shall be referred to as the “Parties.”
WHEREAS, the client seeks therapeutic services from the therapist, and in the course of such services, it may be necessary for the client to disclose personal, sensitive, or confidential information; and
WHEREAS, the therapist agrees to maintain the confidentiality of all information shared by the client during the therapeutic sessions, subject to the limitations outlined in this Agreement.
NOW, THEREFORE, in consideration of the mutual promises and covenants contained herein, the Parties agree as follows:
1. Confidentiality Obligations:
a. The therapist agrees to treat all information disclosed by the client, whether oral, written, or otherwise, as strictly confidential.
b. The therapist shall take reasonable measures to protect the confidentiality of the client’s information and shall not disclose or reveal such information to any third party without the client’s express written consent, except as provided for in Section 2 of this Agreement.
c. The therapist shall inform other consultants or associates who may have access to the client’s information about the confidential nature of the information and ensure that they abide by the terms of this Agreement.
2. Permitted Disclosures:
a. The therapist may disclose the client’s information in the following circumstances:
- If required by law or by a court order, the therapist may be compelled to disclose the client’s information. However, the therapist shall make reasonable efforts to notify the client in advance of any such disclosure, unless prohibited by law.
If the therapist believes, in good faith, that the client poses a threat of serious harm to themselves or others, the therapist may disclose relevant information to appropriate individuals or authorities in order to prevent harm.
- If the client discloses, or it is suspected, that there is abuse or harm neglect of children or vulnerable adults (i.e., the elderly, disabled/incompetent), the therapist must report this information to the appropriate agency and / or legal authorities.
- Parents or legal guardians of non-emancipated minor clients have the right to access the clients’ records.
b. The therapist may use anonymized and de-identified information from the client’s case for research, teaching, or statistical purposes, as long as the client’s identity remains protected.
3. Term and Termination:
a. This Agreement shall remain in effect for the duration of the therapeutic relationship between the therapist and the client, including any post-termination obligations.
b. Notwithstanding the termination of the therapeutic relationship, the obligations of confidentiality set forth in this Agreement shall continue to bind both Parties indefinitely.
4. Entire Agreement:
This Agreement constitutes the entire understanding between the therapist and the client regarding the confidentiality of information shared during the therapeutic sessions and supersedes any prior agreements, discussions, or understandings, whether oral or written.
IN WITNESS WHEREOF, the Parties have executed this Confidentiality Agreement as of the date first written below.
By signing below, I agree to the above assumptions of risk and limits of confidentiality and understand their meanings and ramifications.
Client Signature (Client’s Parent/Guardian if under 18)
Today’s Date : _________________
Therapist’s Signature
Today’s Date : _________________
Note: The type of information that may be requested includes: types of service, dates/times of service, diagnosis, treatment plan, description of impairment, progress of therapy, case notes, summaries, etc.