"OUR JOURNEY THROUGH LIFE"
PRIVACY AGREEMENT (HIPPA)
This document outlines my rights to privacy under the act of (HIPPA), which this professional is mandated to follow.Information discussed during sessions shall be held in strict confidence except for the following situations:
· In the event of harm to self or others.
· -In the event of suspected child abuse
· -In the event of suspected elder abuse
· In the event of a Judge’s subpoena ordering the professional to disclose information.
I understand this document and have been provided a copy upon request.
Printed Signature of Client: ___________________________________
Signature of Client: ___________________________________
Printed Name of Parent or Guardian if Client is a Minor: ___________________________________
Signature of Parent or Guardian if Client is a Minor: ___________________________________