David A. Yeats M.S.W., L.C.S.W.
Psychotherapy and Consultation Services

(Please read this statement and sign below):

The Practice of Psychotherapy involves risks and responsibilities for client and therapist alike. A client shows great courage to open herself or himself to self examination and growth in the presence of another human being. It is the responsibility of the therapist to honor and respect each client and to render the best possible service as understood and agreed to by both client and therapist.
There are several circumstances under which confidentiality may be broken. A therapist has a legal and moral obligation to report child abuse as well as threat of serious harm to the client herself or himself or to others.  Occasionally, a therapist may be subpoenaed by the courts to testify, and on very rare occasions, information may be released to the Social Work Licensing Board in the event of a grievance filed by a client. In addition, a client’s identity may be revealed to appropriate persons regarding payments in default. Other than in those situations, a client can expect absolute confidentiality about the nature of the work being done, or even the fact of the client’s involvement in therapy.
Before any information can be shared with others, clients complete a written and signed specific release of information authorizing the sharing of information with specific persons or agencies.
Any irregularities or concerns, including sexual intimacy in the context of psychotherapy, should be reported to Social Work Licensing Board, 1560 Broadway, Suite 1350, Denver Colorado 80202.  The phone number is (303) 894-7766.

[By signing below, you are documenting that you have read, understand, and agree to both the Introductory Information and the Client Rights Disclosure Statement.]

Client Signature_________________________________________________________ Date __________________