Confidentiality Agreement

In filling out this form digitally, you are agreeing that your electronic signature (typing your name) is the legally binding equivalent of your handwritten signature.

All clinical information shared with my therapist will remain confidential within their service except where they believe there may be a risk of harm to myself or others, or where there’s a legal duty of disclosure.

My therapist has case supervision with their supervisor where a broad outline of my case may be discussed as a part of the supervisory process and that no identifying details will be revealed.

I have read and understood the HGI Information for Clients sheet, including the section about use of questionnaires and how the data will be used in service evaluation and research, and I understand that by ticking the box below I am giving permission for my anonymised data to be used for service evaluation and research and that I can withdraw my consent to this at any time by contacting my therapist.

My personal information will be kept in accordance with the Data Protection legislation. By ticking the box opposite, I consent to information about me being held by the therapist, which means that they will: