Substance Abuse Treatment Confidentiality Agreement
Client Name
Date of Birth
Treatment Facility Name
Confidentiality Policy
I understand that all information shared during treatment is confidential and will not be released without my written consent, except as required by law.
I acknowledge my responsibility to respect the privacy of other clients and not to disclose information learned during group or individual sessions.
I have been informed of the exceptions to confidentiality, including mandatory reporting laws.
Additional Terms or Notes
Client Signature
Date
Staff Signature
Date