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| Life Coaching Limits of Confidentiality |
Information discussed in the coaching or psychological evaluation will be incorporated into the Coaching (or
Psychological) Evaluation report.
1. This report will be sent to the referring source and any other individuals/agencies identified on the Release of
Information signed prior to the evaluation.
2. If the fee for this evaluation is being paid by an insurance company or other agency, it may be necessary to
send a copy of the report to that agency to secure reimbursement, as noted in the signed Authorization for
Payment of Benefits.
3. The client may request a report be sent to another person or agency at any time in the future by completing an
additional Release of Information.
4. This report, and any other information discussed in the evaluation, is confidential, and it will not be shared
without written permission except under the following conditions:
5. The client threatens suicide.
6. The client threatens harm to another person(s), including murder, assault, or other physical harm.
7. The client reports suspected child abuse, including but not limited to, physical beatings, and sexual abuse.
8. The client reports abuse of the elderly.
State law mandates that mental health professionals may need to report these situations to the appropriate
persons or agencies.
In addition, if the client is involved in a legal action and claims mental health issues related to the legal action (i.
e., plea of “Not Guilty by Reason of Insanity,” or claiming emotional harm in a lawsuit), mental health records
may be required to be released.
Communications between Cristin Reichmuth, M.A., and the client will otherwise be deemed confidential as
stated under California state law.
Having read and understood the above, I agree to the limits of confidentiality.
____________________________________ ____________
Name of Client (and Guardian, if applicable) Date
__________________________
Signature of Client
__________________________
Signature of Guardian
__________________________
Cristin A. Reichmuth, M.A.
Life Counselor
Please print (2) copies, sign both, and bring them with you to your initial meeting.
Psychological) Evaluation report.
1. This report will be sent to the referring source and any other individuals/agencies identified on the Release of
Information signed prior to the evaluation.
2. If the fee for this evaluation is being paid by an insurance company or other agency, it may be necessary to
send a copy of the report to that agency to secure reimbursement, as noted in the signed Authorization for
Payment of Benefits.
3. The client may request a report be sent to another person or agency at any time in the future by completing an
additional Release of Information.
4. This report, and any other information discussed in the evaluation, is confidential, and it will not be shared
without written permission except under the following conditions:
5. The client threatens suicide.
6. The client threatens harm to another person(s), including murder, assault, or other physical harm.
7. The client reports suspected child abuse, including but not limited to, physical beatings, and sexual abuse.
8. The client reports abuse of the elderly.
State law mandates that mental health professionals may need to report these situations to the appropriate
persons or agencies.
In addition, if the client is involved in a legal action and claims mental health issues related to the legal action (i.
e., plea of “Not Guilty by Reason of Insanity,” or claiming emotional harm in a lawsuit), mental health records
may be required to be released.
Communications between Cristin Reichmuth, M.A., and the client will otherwise be deemed confidential as
stated under California state law.
Having read and understood the above, I agree to the limits of confidentiality.
____________________________________ ____________
Name of Client (and Guardian, if applicable) Date
__________________________
Signature of Client
__________________________
Signature of Guardian
__________________________
Cristin A. Reichmuth, M.A.
Life Counselor
Please print (2) copies, sign both, and bring them with you to your initial meeting.
| Click here to order the Body and Mind Solution's Feelings Word Chart. Created with Stanford mental health professionals! |
| © Copyright 2005, Cristin Reichmuth, M.A.. Material provided on this web site is for educational and/or informational purposes only. This web site does not offer either online services or medical advice. No therapeutic relationship is established by use of this site. If you have comments or questions, please contact: info@bodyandmindsolutions.com. |