Informed Consent to Participate in Psychological Services and Limits of Confidentiality
Record #
Informed Consent to Participate in Psychological Services and Limits of Confidentiality
I hereby authorize Angel Enrique Pacheco, Ph.D., C.Psych., his Assistants, and/or Associates to provide the professional services in psychology they may deem necessary while consulting, interviewing, assessing, and/or treating me, and/or the person(s) under my responsibility listed as follows:
NAME DATE OF BIRTH (dd-Mmm-yyyy)
- I provide the present authorization in my condition of PARENT – TUTOR – LEGAL REPRESENTATIVE (Circle One) of said minor(s).
- The purpose, process, and the possible consequences of participating in psychological services have been explained to me.
- I understand that my participation in psychological services is voluntary, and that the information collected and/or that I provide will be kept confidential, except that I understand that confidentiality could be breached by Dr. Pacheco, his Assistants, and/or Associates under the following circumstances:
- Where information is required/permitted by law or subpœnaed by court;
- Where a client presents a danger to self, to others, to property, or is gravely disabled or when a client’s family member(s) or significant other(s) communicate(s) to Dr. Pacheco, his Assistants and/or Associates that the client presents a danger to self or others;
- Where there is information involving serious bodily harm to yourself or others (e.g., assault, suicide) or a crime that has been or will be committed;
- If you have been sexually abused by a Regulated Health Care provider;
- Where you disclose or there is information to reasonably suspect that a child under age sixteen, dependent, or elder is at risk for physical, sexual, emotional abuse, or neglect, or may be in need of protection as directed by law; and/or,
- When any form of illegal behavior, or threatened illegal behavior, against Dr. Pacheco, his Assistants, and/or Associates, their families, property, or neighborhood occurs, this will be reported to the police and/or other external agencies, and necessary information will be disclosed to permit the investigation. Such behavior would include, but not be limited to, bodily harm, harassment, trespass, theft, fraud, or vandalism.
- I understand that I can refuse to answer questions and that if I choose to terminate treatment, I will inform and discuss this with my therapist.
- I understand that my treatment takes place within a multidisciplinary team, so information about my progress may be shared with other professional staff members in this practice. I am aware that my therapist will write a report regarding my progress and that this report will be placed on my Psychology file. Copies of this report can be released to others with my consent, or without my consent if subpœnaed by the court.
IMPORTANT NOTICES:
If required, call Dr. Pacheco and, if not available immediately, please leave a voice mail message with your name, telephone number, and a brief description of the situation. Your call will be answered as soon as possible.
In the event of an emergency, call 911, or go to the nearest Hospital Emergency Room, where you will be assisted.
By signing this form, I confirm that:
- I have read this form or it has been read to me, and that I have received a copy;
- I have received a copy of the Privacy and Confidentiality Policy Summary, of the Privacy Policy, and of the Informed Consent for E-Mail or Text Communication;
- I discussed and understand the contents and situations in which disclosure of my protected health care information may occur;
- I understand the circumstances where Psychology staff will need to share information related to my case; and,
- I understand and agree with all the points above.
ACCEPTED IN ACCORDANCE:
Printed Name Signature Date
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