Adjustment Guidance
Confidentiality Agreement
Kisstopher Musick, PhD

What to expect:

As a rule, I will keep the information you share with me during our individual sessions confidential unless I have consent to disclose certain information. There are, however, important exceptions to this rule. In some situations, I am required by law or by the ethics guidelines of my profession to disclose information, whether or not I have permission. I have listed some of these situations below.

Confidentiality cannot be maintained when:

You or a family member is doing things that could cause serious harm, even if the actions are not intended to cause harm. In these situations, I will need to use my professional judgment to decide whether a third party should be informed, such as the authorities, a specific individual, or a group.

You or a family member is involved in a court case and a request is made for information about adjustment guidance. If this happens, I will not disclose information without your written agreement unless the court requires me to do so. I will do all I can within the law to protect your confidentiality, and if I am required to disclose information to the court, I will inform you that this is happening.

Communicating with your Doctors:

Your doctor and I may need to work together if you need to take medication. I will obtain your permission in advance to share information with your doctor. The only time I will share information with your doctor without your permission is if you require immediate medical attention.

Signing below indicates that you have reviewed the policies described above and understand the limits to confidentiality. If you have any questions as we progress, you can ask them at any time.

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Signing below indicates that you have reviewed the policies described above and understand the limits to confidentiality. If you have any questions as we progress, you can ask them at any time.

Signature _______________________________________ Date

Adjustment Specialist Signature________________________________ Date