Couple's Informed Consent & Limits of Confidentiality

Pre-Marital Prep Course (4-hour)

I have chosen to participate in the Pre-Marital Prep Course with Karen E Engebretsen, PsyD., LLC.  My choice has been voluntary and I understand that I MUST complete all 4 hours of the course in order to receive the CERTIFICATE for the Marriage License in Broward County, Florida.

 I understand that some material may be discussed which will be upsetting in nature.  I also acknowledge that, in this process, some significant unanticipated changes in my thinking and attitude may occur as a result of exploring relationship issues which may, in turn, necessitate further exploration in Individual therapy or Couples therapy.

 I undestand that there is no assurance that I will feel better.  I also understand that material may be discussed which will be upsetting in nature.  I also acknowledge that, in the therapy process, some significant unanticipated changes in my thinking and attitude may occur as a result of exploring problems and relationship concerns which caused me to consider therapy.

 I understand that confidentiality of records and information collected about me will be held or released in accordance with State and Federal laws and guidelines. I understand that confidentiality may be breached under the following circumstances:

  1. a)  if I sign a waiver requesting release of information
  2. b) if a court orders the release of my records
  3. c) if I raise my mental status or competency in a legal proceeding
  4. d) if there is reason to believe that there is clear and immediate probability that I will seriously

        harm myself or others or be a potential harm to myself or others including the therapist or physical abuse or any sort as proscribed by the laws of the State of Florida or of the Federal legal system.

  1. e) if there is evidence or strong suspicion of child or elder (or vulnerable adult) abuse

Duty to Warn and Protect

When a patient discloses intentions or a plan to harm another person, the mental health professional is required to warn the intended victim and report this information to legal authorities. In cases in which the patient discloses or implies a plan for suicide, the health care professional is required to notify legal authorities and make reasonable attempts to notify the family of the client.

 Insurance Information: I understand that no insurance can be used for this course.

 In order to provide quality assurance and quality treatment, I understand that my case information may be shared with another licensed clinician who, with my knowledge and consent as evidenced by my signature on this document, will hold all information in confidence and accordance with State and Federal laws.

**I have read the above and have been given the opportunity to ask questions about the basic rights of individuals participating in psychotherapy.  These rights include:

    1)  The right to be informed of the various steps and activities involved in receiving services.

     2)  The right to confidentiality under federal and state laws relating to the receipt of services.

     3)  The right to humane care and protection from harm, abuse, or neglect.

     4)  The right to make an informed decision whether to accept or refuse treatment.

     5)  The right to consult with counsel and select practitioners of my choice and at my expense.

  ________________________________________                                                _____________

Patient's signature (or guardian if patient is a minor)                                               Date

 ________________________________________                                               _____________

Witness' Signature                                                                                                    Date