Consent of Treatment Form

and Limits of Liability

Download form or complete the electronic form below.


    Limits of Services and Assumption of Risks:

    Therapy sessions carry both benefits and risks. Therapy sessions can significantly reduce the amount of distress someone is feeling, improve relationships, and/or resolve other specific issues. However, these improvements and any “cures” cannot be guaranteed for any condition due to the many variables that affect these therapy sessions. Experiencing uncomfortable feelings, discussing unpleasant situations and/or aspects of your life are considered risks of therapy sessions.

    Limits of Confidentiality:

    What you discuss during your therapy session is kept confidential. No contents of the therapy sessions, whether verbal or written may be shared with another party without your written consent or the written consent of your legal guardian. The following is a list of exceptions

    Duty to Warn and Protect

    If you disclose a plan or threat to harm yourself, the therapist must attempt to notify your family and notify legal authorities. In addition, if you disclose a plan to threat or harm another person, the therapist is required to warn the possible victim and notify legal authorities.

    Abuse of Children and Vulnerable Adults

    If you disclose, or it is suspected, that there is abuse or harmful neglect of children or vulnerable adults (i.e. the elderly, disabled/incompetent), the therapist must report this information to the appropriate state agency and/or legal authorities.

    Prenatal Exposure to Controlled Substances

    Therapists must report any admitted prenatal exposure to controlled substances that could be harmful to the mother or the child


    Parents or legal guardians of non-emancipated minor clients have the right to access the clients’ records.

    Insurance Providers

    Insurance companies and other third-party payers are given information that they request regarding services to clients.

    The type of information that may be requested includes: types of service, dates/times of service, diagnosis, treatment plan, description of impairment, progress of therapy, case notes, summaries, etc.

    By signing below, I agree to the above assumption of risk and limits of confidentiality and understand their meanings and ramifications.

  • Date Format: MM slash DD slash YYYY

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Saturday and Sunday — Closed

VI Medical Foundation Building

9150 Estate Thomas, Suite 210

St. Thomas, VI 00802