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Counseling Confidentiality Form Template

Establish Trust and Security with Your Clients

Maintaining confidentiality is crucial for a productive therapeutic relationship. This Counseling Confidentiality Form Template is designed for licensed counselors, therapists, and mental health professionals to communicate essential privacy policies clearly. By using this form, you can protect client information, ensure compliance with legal requirements, enhance trust in your practice, and create a safe space for open dialogue. Explore the template to streamline your onboarding process and strengthen your client relationships.

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Client full name
Date of birth
Email
Mobile phone
I have reviewed the counseling confidentiality policy provided to me.
Yes, I have reviewed it
No, I have not reviewed it
I prefer to discuss before agreeing
Please acknowledge the legal limits to confidentiality that you understand may require disclosure.
Imminent risk of harm to self
Imminent risk of harm to others
Suspected abuse or neglect of a child, elder, or dependent adult
Court order or other legal requirement
Supervision or consultation to support quality of care (minimum necessary information only)
Billing, payment, and healthcare operations as permitted by law
As otherwise required by applicable law
I understand I may withdraw my consent in writing at any time.
Yes
No
You may contact me with appointment reminders by:
Text message
Email
Phone call
Do not send reminders
Voicemail permission for the phone number provided:
Do not leave messages
Leave a callback number only
Leave a detailed voicemail
I understand that email and text may not be fully secure and consent to their use as selected above.
Yes
No
Emergency contact full name
Relationship to you
Emergency contact phone
Permission to contact this person if there are safety concerns
Yes
No
Notice of Privacy Practices (HIPAA) acknowledgment
I received and acknowledge
I was offered but declined a copy
Not applicable
Is the client a minor?
Yes
No
Client typed signature (full name)
Date
Parent/guardian typed signature (full name, if applicable)
Relationship to client (if applicable)
Date (if applicable)
I consent to participate in counseling under the terms described above.
Yes
No
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Paper art illustration depicting a counseling confidentiality form with professional design elements and text layout.

When to use this form

Use this template when you need a clear, client-facing therapist confidentiality statement for therapy intake, telehealth onboarding, or couples/family work. It explains what you keep private, the legal limits (risk of harm, abuse reporting, court orders), and how you handle records. Private practices, school counselors, and group clinics benefit by setting expectations early and reducing disputes. Pair it with the GDPR Consent form to cover data rights and storage, and with the Withdrawal of consent form so clients know how to change their permissions. You can also align language with your Psychology informed consent form to keep your documents consistent. Outcome: clients sign with confidence, and you protect your practice.

Must Ask Counseling Confidentiality Questions

  1. Do you understand what information is confidential and the legal exceptions?

    This confirms the client grasps the scope and limits of privacy, reducing surprises later. Clear consent here helps you comply with law and practice standards.

  2. How may we contact you and leave messages without sharing sensitive details?

    Preferred channels and message rules prevent accidental disclosures. It also speeds scheduling and follow-up because your team knows what is safe.

  3. Do you consent to using email, text, or telehealth, knowing the related privacy risks?

    Some tools carry security trade-offs; explicit consent avoids misunderstandings. Documenting this choice protects both the client and your practice.

  4. Who, if anyone, can we share information with, and for what purpose?

    Naming people (e.g., physician, school, partner) and reasons prevents scope creep. You keep disclosures minimal and targeted.

  5. How can you change or withdraw consent in the future?

    Stating the process upfront empowers clients and reduces friction later. It also ensures your records reflect current permissions.

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