Be Heard

Confidentiality agreement

All interactions which take place in the setting of therapy are considered confidential. This includes requests by telephone, all interactions with this counselor, any scheduling or appointment notes, all session content records and any progress notes that your therapist will take during your sessions. Your therapist will not even verify that you are a client. You may choose to give your therapist permission in writing to release any or specific information about you to any person or agency that you designate.

Client’s Rights

1. You have the right to ask any questions about procedures used during therapy. If you wish, your therapist will explain their usual methods of therapy practice to you.
2. You have the right to refuse the use of any therapeutic technique. Your therapist will inform you if they intend to use any unusual procedures and will explain any risks involved
3. You have the right to learn about alternative methods of treatment. Your therapist will discuss these with you during your time  together

Limits to this agreement

1. In some legal proceedings a judge may issue a court order. This would require your counselor to testify in court.

1. If your therapist learns of or believes that there is physical or sexual abuse or neglect of any person under 18 years of age, He/she must report this information to child protection services
2. If your therapist learns of or believes that an elderly person, or disabled person is being abused or neglected, He/she must file a report with the appropriate state agency that handles elder abuse

4. If your therapist learns of or believes that you are threatening serious harm to another person, he/she is obligated to report this. This can be in the form of telling the person who you have threatened, contacting the police or placing you into hospitalization.
5. If there is evidence that you are a danger to yourself and your therapist believes that you are likely to kill yourself unless protective measure is taken, he/she MAY be obligated to seek hospitalization for you or to contact family members or others who can help provide protection. In this case, please be sure to provide a trusted, emergency contact for the sake of your well-being below.

1. There may be times when your therapist may consult with outside sources about cases. In these cases, no personally identifiable information will be used to discuss this case. However, discussion topics will be used in order to ensure that your therapist is getting and giving the best assistance possible. The persons with whom our therapist will discuss cases with are legally bound to keep information confidential.
2. In case of any mishap between you and your therapist, thelistener.pk will not be responsible for it. It will remain between you and your therapist to sort it out.

I have read and discussed the above information with my therapist. I understand the nature and limits of confidentiality.

______________________________                                _________________                

 Client/Legal guardian’s signature                                   Therapist’s signature 

Emergency Contact:       _______________________

CNIC No:        ______________________________