Informed Consent for Treatment

Please type your initials after each of following statements below in the box provided on the right to indicate that you have read and understand this release.

I understand that all information shared with the clinicians at CPI is confidential and no information will be released without my consent.  During the course of treatment at CPI, it may be necessary for my therapist to communicate with providers to determine the best treatment for my particular case.  While written authorization will not be requested, prior to any discussion with CPI providers, I understand that my therapist will discuss CPI communications with me.  In all other circumstances, consent to release information is given through written authorization.  Verbal consent for limited release of information may be necessary in special circumstances.  I further understand that there are specific and limited exceptions to this confidentiality which include the following:

  1. When there is risk of imminent danger to myself or to another person, the clinician is ethically bound to take necessary steps to prevent such danger.
  2. When there is suspicion that a child or elder (65+) is being sexually, physically or emotionally abused or is at risk of such abuse, the clinician is legally required to take steps to protect the child, and to inform the proper authorities. (see Penal Code11166.05).
  3. When a valid court order is issued for medical records, the clinician and the agency are bound by law to comply with such requests.      Re