I am committed to preserving the confidentially and privacy of all my clients. However, some state laws specify certain circumstances when a mental health professional may be required to break confidentiality. I am required by Florida law to inform all my clients of these limits on confidentiality. Special circumstances when a disclosure situation may arise include:
1.     If the client presents a clear and present danger to himself and refuses to accept appropriate treatment, the clinician may release information to protect the client;
2.     If the client communicates to the clinician an actual threat of physical violence against a clearly identified or reasonably identifiable victim(s), relevant information may be released to protect the potential victim(s);
3.     If the client has a history of physical violence which is known to the clinician, and the clinician has a reasonable basis to believe that there is a clear and present danger of physical violence against a clearly identified or reasonably identifiable victim(s), relevant information may be released to protect the potential victim(s);
4.     If there is a threat of imminently dangerous activity by the patient against himself or another person(s), the clinician may disclose client communications for the purpose of placing or retaining the client in a psychiatric hospital;
5.     If the client introduces his mental condition as an element of claim or defense in a legal proceeding (except one involving child custody or adoption) the judge may order the clinician to disclose confidential client communications;
6.     If, after the death of a client, any party acting on behalf of the decedent introduces evidence of the client’s mental condition as an element of defense, the judge may order the clinician to disclose confidential client communications;
7.     In any case of child custody or adoption, the judge may order the clinician to disclose confidential client communications if the judge determines that the clinician has evidence bearing significantly on the client’s ability to provide suitable care of custody and it is more important to the welfare of the child that the communication be disclosed than that the relationship between client and clinician be protected (in cases of adoption, or dispensing with consent to adoptions, the judge must determine that the client has been informed that communications to the clinician would not be privileged);
8.     If the client initiates legal action (e.g., malpractice, criminal or license revocation) against the clinician, the clinician may disclose confidential client communications if disclosure may be necessary or relevant to the clinician’s defense;
9.     The clinician may provide diagnostic or treatment information to an insurance company or review board, nonprofit hospital or medial service corporation, or health maintenance organization for the purpose of administration or provision of benefits and expenses;
10.   If the clinician, in his professional capacity, has reasonable cause to believe that a child under the age of eighteen years is suffering serious physical or emotional injury resulting from abuse inflicted upon the child (including sexual abuse), or from neglect (including malnutrition), or who is determined to be dependent upon an addictive drug at birth, the clinician may be obligated to report this information to the Florida Department of Social Services;
11.   If the clinician has reasonable cause to believe that an elderly person (over the age of sixty years old) or a handicapped or disabled person over the age of eighteen years old has died or is suffering abuse, the clinician may be obligated to report this information to the proper state agency;
12.   Information acquired by a clinician in the course of his professional practice of psychology may be disclosed to another professional as part of a professional consultation;
13.   If a judge compels the clinician to reveal confidential client information;
14.   If the client(s) fail to pay their bill, a clinician may file for action in a claims court. No information about the client’s communications to the clinician may be revealed unless it is relevant to the claim action or arguments introduced by the client as defendant;

Apart from the above listed exceptions, client information may only be shared with the express written consent of the patient or parent/guardian.

If you have any questions about confidentiality or this statement, please discuss them with me before you sign below.

I/WE HAVE READ THE STATEMENT ABOVE REGARDING THE LIMITS OF CONFIDENTIALITY AND PRIVACY. I/WE UNDERSTAND THE LIMITS TO CONFIDENTIALITY AND THE SPECIAL SITUATIONS WHERE DISCLOSURES MIGHT OCCUR.