Additional Participant Disclosure Statement and Consent: Adult


Center for Family Development

1258 High Street, Eugene, OR 97401 541-342-8437 / Fax 541-242-2999

Client's Name:     Date of Birth:

Additional Participant Disclosure Statement and Consent: Adult

Additional Participant's Name:

Participation in Treatment Services

  • I have been invited to participate in Client’s therapy sessions. I will be involved for one or more of the following reasons:
    • To be a resource and to provide additional information for the therapist
    • To discuss ways I can be helpful to Client
    • To participate in family therapy, which will be aimed at helping the family
  • I am not a client of Client’s therapist and I am not here to receive therapy for myself.
  • I understand that I may experience some personal benefits from attending these sessions, but also that there may be periods during my participation in Client’s therapy or during family therapy in which I may experience emotional discomfort, changes in relationships, and temporary worsening of problems. I understand that the goal and hoped for benefit of the therapy is the resolution of Client’s behavioral health concerns, and that I or my family may need to obtain services outside of this therapy to address any issues that do not fall within that scope.
  • I will not be charged for any sessions I attend.

Confidentiality and Documentation

  • I understand that information I disclose to Client’s therapist may be shared with Client. Such information will not be confidential or privileged, unless otherwise required by applicable law, rule, or regulation.
  • The therapist may document what I share as part of Client’s treatment records. I do not have a right to inspect or receive copies of such treatment records, unless authorized by Client.
  • If Client’s treatment records are disclosed to other parties as the result of legal requirements, legal process, or Client’s authorization, I will not have a right to prevent such disclosure.

Mandated Reporting

  • If, during my participation in Client’s therapy, I reveal to therapist past or current abuse of a person who is in a protected category, whether that person is myself or another individual, the therapist will disclose and report such information as required by Oregon law. Individuals in the protected categories are children, elderly persons, developmentally disabled persons, and persons receiving mental health services covered by Oregon Health Plan or other public funding.
  • If I threaten to harm myself or others, Center for Family Development is required to intervene, which may include a report to the appropriate agency and/or authority.
  • In the event of threatened harm to any individual, the therapist may warn the intended victim(s) by the most efficient means available.

By signing below, I acknowledge that I have read and understand this Disclosure Statement and Consent form and agree to its terms.

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Document name: Additional Participant Disclosure Statement and Consent: Adult
lock iconUnique Document ID: 7cc601d5a5eac826189042bd92ec5d8603a1e49d
Timestamp Audit
June 2, 2020 3:23 pm PSTAdditional Participant Disclosure Statement and Consent: Adult Uploaded by Jason Dooley - jdooley@c-f-d.org IP 65.157.96.202
June 2, 2020 4:27 pm PSTCFD Main - main@c-f-d.org added by Jason Dooley - jdooley@c-f-d.org as a CC'd Recipient Ip: 71.238.126.129
June 4, 2020 4:06 pm PSTCFD Main - main@c-f-d.org added by Jason Dooley - jdooley@c-f-d.org as a CC'd Recipient Ip: 65.157.96.202