Limits of Confidentiality


(NOTE: Page is Formatted the same as our Hard Copy Sheet except for Online Submit Option)

Client’s name: _______________________________________________________

All information released to ______________________________ is strictly confidential.

Counsellor’s name


In order for any information or documentation to be released to anyone, a consent form must be signed by a parent/guardian or client of age.


Confidentiality cannot be maintained in the following circumstances:

  • when disclosed intended behaviour may cause harm to self;
  • when disclosed intended behaviour may cause harm to others;
  • when disclosed behaviour impacts the safety of a child/adolescent under the age of 16; by law such information must be reported to Child Youth & Family Services; and
  • when the court subpoenas information to be released.


Outside these legal and ethical principles, all information is treated as confidential.  Given the complexities of working with families, information could be inadvertently shared with other family members.  Clients must specifically request the confidentiality of information that they do not want divulged to other family members.


I have read and understood the above information, which has been reviewed and explained to me by ______________________________.

Counsellor’s name


Adults and adolescents over 16 years of age:

Signature: _________________________________  Date: ____________________

Signature: _________________________________  Date: ____________________

Witness : __________________________________  Date: ____________________

(Rev. 2017..09)