**Please contact us to obtain new patient registration forms.**
If you would like your psychologist to collaborate with another individual, professional, or entity, please download & complete the form below:
Authorization for Release of Information
Confidentiality & Privacy Policy
All information disclosed within sessions and the written records pertaining to those sessions are confidential and will not be revealed to anyone without your written permission except under certain conditions. The following are circumstances where disclosure is required or may be required by law:
- When there is a reasonable suspicion of child, dependent, or elder abuse/neglect. I am mandated to report this information to the Indiana Department of Child Services or the Adult Protective Services agencies, depending on the age of the individual at risk.
- When a patient presents as a danger to him/herself. I may be required to seek hospitalization or contact family members or others who can help provide protection.
- When a patient presents as a danger to others. I may have to take protective actions including notifying the potential victim, contacting the police, or seeking hospitalization.
- When a patient presents as a serious and present danger to the health of others. If a patient engages in behaviors which may transmit a dangerous communicable disease or indicates a careless disregard for the transmission of the disease to others, I may be required to take protective action which could include notifying the potential victim or contacting the police.
- When there are legal proceedings by or against you. If your mental status is placed at issue in litigation, the defendant may have the right to obtain the records and/or testimony by me. Also, if I receive a court order to turn over my records, I am required to do so by law.
Please note: For patients under 18 years of age, please be aware that the law allows parents/guardians the right to examine treatment records.