I understand that my participation is voluntary, and that at any time I can withdraw, decline to answer any question or to participate in any exercise. I certify that I do not have a personal or client relationship with Dr. Mandel. I am not responsible for any therapy fees with Dr. Mandel, except in those cases, such as parent or legal guardianship, in which I would normally be responsible for the client's therapy fees or in the case where I have agreed to be financially responsible for the client’s therapy fees.
I understand that what I say in session(s) may be discussed between Dr. Mandel and the client. (Note: It is sometimes possible to maintain the privacy of our communications. If you wish to maintain some privacy concerning some aspects of our communications, we should discuss it before any information is communicated by you).
As a collateral ally I understand that I have certain rights and requirements pertaining to confidentiality, as well as some limits to that confidentiality. I am expected to maintain the confidentiality of the client. I understand that although Dr. Mandel will not maintain a chart on me nor make any diagnosis, notes about me which pertain to my relationship with the client may be entered into the client's chart, as well as some of my comments about the client. Because the client has rights to his/her confidentiality, I may not request to access that chart without the written consent of the client. The client however, pursuant to state and federal laws, can access his/her chart. I understand the following exceptions to confidentiality, which pertain to both the client and myself:
- If Dr. Mandel suspects abuse or neglect of a child or a vulnerable adult, she is required to file a report with the appropriate agency.
- If Dr. Mandel believes that I am a danger to myself (suicidal) she is required take actions to protect my life.
- If I threaten serious bodily harm to another, Dr. Mandel is required to take necessary actions to protect that person.
- If a court requires that Dr. Mandel submit information or testify in a case involving me or the client, she must comply. Please note that Dr. Mandel will do so only if the court requires it, not merely if an attorney requests information.
- If insurance is used to pay for the treatment, the insurance company may require Dr. Mandel to submit information about the treatment before they will pay for treatment.
I understand that my role as a collateral may create some anxiety or emotional distress in me. It may also expose or create some emotions in my relationship with the client. I understand that, if I find myself experiencing any emotional difficulties, and I am not currently in psychotherapy, I should let Dr. Mandel know so that he can suggest resources or referrals for me.
I certify that all of the above information has been explained and discussed with me by Dr. Mandel, and that I have had an opportunity to ask any questions.