Confidentiality Consent for Substance Abuse Counseling

This form explains how information shared during substance abuse counseling is confidential, and under what circumstances it may be disclosed in accordance with applicable laws and regulations. Please read and acknowledge your understanding and consent below.

Confidentiality Agreement

• Information disclosed during counseling sessions is confidential and will not be shared without your written consent.
• Certain exceptions to confidentiality may apply, including but not limited to:
  • Imminent risk of harm to yourself or others
  • Suspected abuse or neglect of a minor, elder, or dependent adult
  • Court order or other legal requirements
• By signing below, you acknowledge that you have read and understood the limits of confidentiality described above.