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As a rule, I will disclose no information about you to anyone, or the fact that you are my patient, without your written consent. My formal Mental Health Record describes the services provided to you and contains the dates/times of our sessions, your diagnosis, mental status, symptoms, progress, brief description of session content, treatment plan, and any psychological testing results. Health care providers are legally allowed to use or disclose records or information for treatment, payment, and health care operations purposes. However, I do not routinely disclose information in such circumstances, so I will require your permission in advance, either through your consent at the onset of our relationship (by signing the attached general privacy policies consent form), or through your written authorization at the time the need for disclosure arises. You may revoke your permission, in writing, at any time, by contacting me.

Limits of Confidentiality

Possible Uses and Disclosures of Mental Health Records without Consent or Authorization

There are some important exceptions to this rule of confidentiality – some exceptions created voluntarily by my own choice, and some required by law. If you wish to receive mental health services from me, you must sign the attached form indicating that you understand and accept my policies about confidentiality and its limits.

I may use or disclose records or other information about you without your consent or authorization in the following circumstances, either by policy, or because legally required:

· Emergency: If you are involved in in a life-threatening emergency and I cannot ask your permission, I will share information if I believe you would have wanted me to do so, or if I believe it will be helpful to you.

· Child Abuse Reporting: If I have reason to suspect that a child is abused or neglected, I am required by law to report the matter immediately to the TN Department of Children’s Services.

· Adult Abuse Reporting: If I have reason to suspect that an elderly or incapacitated adult is abused, neglected, or exploited, I am required by law to immediately make a report and provide relevant information to the TN Department of Human Services' Adult Protective Services

· Health Oversight: TN law requires that licensed psychologists [social workers; counselors] report misconduct by a health care provider of their own profession. If you describe unprofessional conduct by another mental health provider of any profession, I will explain to you how to make such a report. If you are yourself a health care provider, I am required by law to report to your licensing board that you are in treatment with me if I believe your condition places the public at risk.

· Court Proceedings: If you are involved in a court preceding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law, and I will not release information unless you provide written authorization, or a judge issues a court order. If I receive a subpoena for records or testimony, I will notify you so you can file a motion to quash (block) the subpoena.

· Serious Threat to Health or Safety: By law, if I am engaged in my professional duties and you communicate to me a specific and immediate threat to cause serious bodily injury or death, to an identified or to an identifiable person, and I believe you have the intent and ability to carry out that threat immediately or imminently, I am legally required to take steps to protect third parties. These precautions may include: 1) warning the potential victim(s), or the parent or guardian of the potential victim(s), if under 18, 2) notifying a law enforcement officer, or 3) seeking your hospitalization. By my own policy, I may also use and disclose medical information about you when necessary to prevent an immediate, serious threat to your own health and safety.

Patient’s Acknowledgement of Receipt of Confidentiality & It’s Limits In Psychotherapy


“The above copy of Dr. Virts’ Notice of Limits of confidentiality in Psychotherapy has been provided. I have read these policies, and I understand that I may ask questions about them at any time in the future.  I consent to accept these policies as a condition of receiving mental health services.”

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