GROUP CONFIDENTIALITY CONTRACT

It is expected that during group sessions, personal information will be discussed. This could be difficult if there is a chance that the information shared in the group became public knowledge. Therefore, it is imperative that what is discussed during group sessions nor be repeated to ANYONE. This includes member disclosure outside of group meetings. This way, open and honest communication with group members can develop.

I understand that my signature on this contract indicates taht I recognized the importance of confidentiality within the group. I will respect each group.I will respect each group member's right to confidentiality. I will always protect the identity of group members and the information shared regarding relationships and situations.

CONSENT TO TREAT

I consent to allow the staff of Adult Youth Services, LLC to assess and enroil me in the appropriate services regarding my needs. Services may include group counseling, individual counseling, case management, assessment, or evaluation. If enrolled, I will be assigned a primary counselor and will be informed of and participate in my service plan.

I can expect the staff of Adult Youth Services, LLC to adhere to the federal and state confidentiality laws. Confidentiality is protected by (CFR 42, art 2). Generally, the program may not say to a person outside the program that you attend the program, or disclose any information identifying you as a person involved with unless:

  1. You have consented in writing on a release of information form.
  2. The disclosure is allowed by a court order.
  3. The disclosure is made to medical personnel in a medical emergency.
  4. The disclosure is made to personnel for research, audit, or program evaluation.
  5. In the event of an ADA interpreter is needed.
  6. You commit/threaten to commit a crime either at the program or against any person who works for the program.
  7. To report suspected child or elder abuse or neglect as authorized and mandated under CRS 1973.
  8. In the event of a stated or implied threat of suicide.
  9. You make a direct threat of homicide where there is a "duty to warn" the intended victim.

I know that treatment in this ficid is not an exact science, and acknowledge that no guarantee has been made to me as the result of evaluations. assessments or other services at Adult Youth Services, LLC. My signature below indicates that I have read and understand my rights:

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