This clinic is bound by the provisions of the Minnesota Privacy Act. No information will be released to persons or agencies outside this office without your consent, except by court order. If anyone wants information from your records or me, your permission in writing is required. Before granting permission, satisfy yourself that the information is really needed, be sure to understand the information being given, and that giving it will help you. You may refuse permission. Information about you, including family and relationship information may be discussed with an appropriate Consultant for the purpose of diagnosis, treatment planning and quality control of services. Consulting aids your treatment and confidentiality binds consultants/colleagues. You may object, and your wishes will be respected unless safety requires otherwise. Please see the guidelines for privacy practices at the end of this informed consent.
LEGAL MATTERS: Please note that by signing this agreement that you are also agreeing that I do not go to court on your behalf or not on your behalf, appear at any depositions, make my notes available to anyone, nor do I talk to any lawyers or lawyer's representatives. This is a confidential relationship and it cannot stay that way if any legal matters are involved, so please know ahead of time that I cannot be involved if you are summoned in a Court action.
MINORS : If you are a minor (under 18 years of age) you have the right to request in writing, that information in your records not be shown to your parents or guardians. You will need to state what information you do not want shown to them. And why you are requesting this. If I am in agreement that it would not be in your best interest for your parents or guardians to be given this information, it will not be shown or shared with them. However, psychotherapy services will not be provided to minors without parental permission.
EXCEPTIONS TO CONFIDENTIALITY
There are five situations in which client confidentially is not maintained:
- If I have knowledge or reasonable cause to believe a child is being neglected or physically or sexually abused, in which case Minnesota Statue (1976 & 6262.656, Subd. 3) requires that such information be reported.
- Maltreatment of Vulnerable Adults (as specified) in the Vulnerable Adults Act (Minnesota & 626.557) must also be reported.
- If I have reason to believe that you present a clear and present danger to yourself or others, I must inform the relevant parties.
- If a specific court order requires disclosure of information.
- If I have knowledge or reasonable cause that a pregnant woman is taking drugs, Minnesota Statutes require that such information be reported.