Therapy Client Confidentiality Preference Form
Client Name
Contact Email
Preferred Method of Communication
Email
Phone
Text Message
Video Call
Other
Preferred Level of Confidentiality
Standard (required by law)
Enhanced (only discuss with client)
Other
Authorization to Share Information
Do you authorize your therapist to share your information with any of the following?
Primary Care Doctor
Family Member
Emergency Contact
None
Additional Confidentiality Preferences or Restrictions
Signature
Date