Collateral Release Form

Collateral Individual Informed Consent Form

Welcome!  You have been invited to participate in the treatment of ________________________________ who is a client of _____________________________

(patient name)_________________________________________ (therapist/examiner name).

Your role as a participant or “Collateral” may be that of a concerned family member or another important figure in this patient’s life. Whatever your role, whether to give

information, to receive information, to support the patient in the treatment, or to help the patient improve his/her relationships, it is important that you are aware of and

agree to what your participation in a session does or does not mean.

Please be aware that your participation does not mean that you are also a patient of the therapist/examiner who is treating _________________________________.

There are no promises or guarantees regarding how your participation may affect you, or the patient, or your relationship with the patient, or your relationships with others.

You should understand that your participation in the session is voluntary.

Please be aware that what occurs in a session with a therapist/examiner and a patient is considered confidential.  Since you will be a part of that confidential session, we hope

that you will also respect that confidentiality and understand that disclosing private, confidential information without the patient’s permission may be hurtful to the patient.

Participation in a psychotherapy session, as a Collateral, may also seem frustrating and may arouse strong, difficult emotions.  You may discover that the way you think about

the world, the way you view your past, present, and future, and the way you relate to others may be altered.  You may be asked to help the patient in ways that may require your

activity either in or out of the patient’s session.

You understand and agree that your participation will be documented in the patient’s record.  Thus, if the patient wishes to release his/her record for any purpose, it is possible

that documentation of your participation in the patient’s session will also be released.

Since you are not the identified client, you cannot bill any insurance company or third party for any fees that are paid for the client’s treatment.

If at any time, the client does not want you included in a session, you agree to stop your participation immediately.

Please do not hesitate to ask the therapist/examiner any questions if any of the above seems unclear or if you do not wish to participate as a collateral.

After you have read this form, please sign your name and the date below indicating that you have understood and agree to what you have read above.  Thank you.

_______________________________________         ______________________________
Signature of Collateral if age 14 or over                       PRINT COLLATERAL NAME ABOVE

__________________________________________________________________      ______________
Signature of Parent or Sole Legal Guardian if Collateral is under 18 years of age               Date

__________________________________________________________________      ______________
Signature of Other Parent if joint custody of Minor Collateral                          Date