Informed Consent & Confidentiality Agreement

1 Confidentiality & Privacy Policy

All interactions between you and your medical practitioner — including appointment scheduling, session content, and your progress records — are strictly confidential. No information will be released to any third party without your explicit, signed written consent, except where mandated or permitted by law.

2 Legal Limits to Confidentiality

Medical practitioners are legally and ethically required to break confidentiality in the following specific circumstances:

• Imminent Risk of Harm: If the practitioner has reason to believe you present an immediate and serious danger of harming yourself or someone else, action must be taken to ensure physical safety.
• Abuse of Vulnerable Individuals: Any suspicion or evidence of abuse, neglect, or exploitation involving a child under 18, an elderly person, or a dependent/vulnerable adult must be reported to protective services immediately.
• Court Orders & Subpoenas: If a judge issues a lawful court order or subpoena, the medical practitioner may be legally compelled to provide specific records or testimony.

3 Clinical Records & Policies

Clinical records are securely stored digitally or physically in compliance with regional privacy laws. Appointments must be cancelled at least 24 hours in advance to avoid a late cancellation fee.

4 Acknowledgment & Signatures

By signing below, you acknowledge that you have read, understood, and agreed to the terms, conditions, and privacy boundaries outlined in this agreement. You have had the opportunity to ask questions regarding these policies.

Patient Signature (type your full name) Patient Email (for your copy) Medical Practitioner Signature Sign & Submit Agreement