Example Client Confidentiality Agreement - Free Download
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Example Client Confidentiality Agreement
Example Client Confidentiality Agreement
CLIENT CONFIDENTIALITY AGREEMENT
I understand that I am legally prohibited from discussing client information other than with current Monarch Cove/
Castlewood West staff, including any past, present and prospective clients.
I understand that I am legally prohibited from posting pictures, video, or information about other clients online in
any format.
I understand that I am legally prohibited from contacting Monarch Cove / Castlewood West Staff, , including
members of my treatment team, via Facebook, Twitter, or other electronic social media websites.
I understand that I must authorize the use of all electronic mail (i.e., email) between myself and member(s) of my
treatment team in writing and conform to all CTC rules and regulations governing email.
I understand that these are conditions of my admission and/or outpatient treatment at Monarch Cove /
Castlewood West Treatment Center and that any breach of client confidentiality may result in immediate
termination from treatment at Monarch Cove / Castlewood West Treatment Center.
_______________________________________________ _________________
Client Signature Date
_______________________________________________ _________________
Parent/Guardian Signature (If Applicable) Date
_______________________________________________ ________________
Facility Witness’s Signature Date
Form Adm Rev. 03/13
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