confidentiality

CONFIDENTIALITY

By signing this form, I consent that Jo Dakin may release information to a specific individual or agency if it has been determined that a vulnerable person (child or elder) is at risk; if I, as a client, am in imminent danger to myself or others; or if a subpoena of records has been requested.

 

I also understand that, at any time, Jo Dakin may discuss aspects of my case with other colleagues keeping my full name and identity completely confidential always unless I have given permission otherwise.

 

 

 

Full Name:    _________________________    Signature: _____________________________
 

Date:             _________________________