CONFIDENTIALITY, DISCLOSURE, AND INFORMED CONSENT FOR PSYCHOLOGICAL SERVICES
CONSENT FORM
Wilson Psychology Group LLC offers psychological services to patients across the state of Alabama. The licensed psychologist you are meeting with is involved in the group partnership doing business as Wilson Psychology Group LLC.
This psychologist is meeting with you to assist you improve your overall mental and physical health. Our first few appointments will involve an assessment of your needs and establishing goals of treatment. If a different behavioral health professional would better meet your needs, we will assist in locating a provider best suited to help you. Your participation in psychological services is completely voluntary, and if you do not want a psychologist to be member of your team of health care providers, you are free to decline. If you have questions about services offered or provided by the psychologist, you are encouraged to ask them at any time.
In order to understand your needs and improve our services, this psychologist may give you screening measures or questionnaires to complete. If such information was ever presented for program evaluation or research purposes, but the results would never identify you personally.
LIMITS OF CONFIDENTIALITY
We consider privacy of utmost importance and will protect it within the boundaries of the law and professional ethics. For treatment purposes and in order to better serve you, information shared during your sessions may be shared with other Wilson Psychology Group LLC staff. When information is used for these consultation purposes, confidentiality is protected by those involved.
This psychologist will not share identifying information that you discuss during a session with individuals outside of the Wilson Psychology Group LLC treatment team unless you sign a separate written authorization form, with a few important exceptions:
Harm to Self: If you are in imminent danger of serious physical harm to yourself, this psychologist is legally required to call medical or emergency personnel in order to obtain help, protection, and possibly hospitalization for you. This does not mean that because you express feelings and thoughts about harming or killing yourself that your privacy will definitely be compromised. There is an important difference between expressing thoughts/feelings versus acting on them. Only if there is determined to be an imminent danger of serious physical harm to yourself will protective action be taken. If you believe you are in imminent danger of harming yourself, you must seek emergency mental health services at a local hospital or by calling 911.
Harm to Others: Similarly, if you report that you intend to seriously harm another person, by law, we must take action to protect the other person.
Abuse of Children: If there is reasonable suspicion that a child is being neglected, physically abused, sexually abused, subjected to willful cruelty or unjustifiable mental suffering, or exposed to domestic violence in the home, by law, the suspicion must be reported to child protective services or a local law enforcement agency.
Abuse of Elders or Dependent Adults: If there is reasonable suspicion that physical abuse, misuse of physical or chemical restraint, neglect, abandonment, isolation, abduction, or financial abuse is occurring against an elderly (age 65 or older) or dependent adult (i.e., an adult with a mental or physical disability), by law, the suspicion must be reported to the appropriate government agency.
Legal Demands: If legal demands to release information are made (such as a court order), we will make every attempt to inform you before any confidential information is released. You are protected under psychologist-patient privilege law. No information can be provided without your (or your legally-appointed representative’s) written authorization, a court order, or compulsory process (a subpoena) or discovery request from another party to the court proceeding where that party has given you proper notice (when required), has stated valid legal grounds for obtaining the information, and we do not have grounds for objecting under state law (or you have instructed us not to object).
When it is necessary to break confidentiality due to any of these exceptions, we will make a reasonable effort to notify you prior to any disclosures so that we can discuss the disclosure before action is taken, and disclosures will be limited to what is necessary.