| ____
Who is the client? (or "who are the clients" ?) |
| | As
expected by referral source _______________________________
As will be described
to third party payer ________________________
As clinically defined by you
_________________________________
|
| ____
What other parties will (or may) participate in the clinical intervention? |
| | As
professional(s)? _______________________________________
As client(s) or collateral(s)?
__________________________________
______________________________________________________
|
| ____
What is your role/relationship with each involved party? |
| | The
Client(s) ______________________________________________
The "non-clients"_________________________________________
Others (referring agency/organization, court, etc.) ________________
______________________________________________________
|
| | ____
Do your roles involve any potential conflicts of interest? |
| | | Do
you have contracts with referral source that limit confidentiality?
Must you
report to "outsiders" about the process? What? To Whom? |
| | | |
| ____
*What are your rules about confidentiality and its limits? |
| | What
are the possible uses of the information you obtain?
What are your rules about
disclosure of confidential information?
Who will have routine access to records/information?
Will
you be providing information/reports to anyone routinely?
What releases will
you require before beginning clinical work?
Will information shared privately
be disclosed to others in couple/family?
Are others expected to behave in a
certain way about confidentiality? |
| | | | |
| | ____
*Do clients/collaterals also have rules about confidentiality and its limits?
|
| | | Rules
about disclosure to each other outside the therapy room?
Rules about disclosure
to others outside the therapy room?
Rules about confidentiality of outside
interactions with e/o? |
| | | | |
| | ____
*What are the arrangements about fees/billing? |
| | | What
is the fee? _______________________________________
Who is responsible for
paying it? ___________________________
Will you be sending statements?
When
is payment due?
What happens if the bill isn't paid? _________________________
|
| | ____
*What is the nature and anticipated course of treatment/intervention? ____
Have you explained that changes in any one family member may affect the
others? ____ Will sessions/meeting
be audio- or video-taped? ____
Other |