Although I am bound by ethical principles to keep information about you confidential, there are certain exceptions to these principles that you should understand prior to entering into the therapeutic relationship.

1. In a case of suspected child abuse, I am required to report this to the appropriate authorities even when this requires breaking confidentiality.
2. If, at some point, I believe that your child’s life or someone else’s life is endangered, I may break confidentiality to warn or prevent harm to your child or another person.
3. If you are using a third party payer (private insurance, managed health care, or Medicare), I may be required to submit reports or information, such as diagnoses, to obtain reimbursement from your insurer. If there are irresolvable difficulties in payment of fees, it may be necessary to turn account names over to an attorney or a collection agency.
4. Under some circumstances, such as custody and divorce litigation, records may be subpoenaed by a judge.
5. If you sign a release of information in order that I may speak or correspond with professionals with whom you have had previous contact, information about you or your child will be divulged with your consent.
6. If you are a legal minor (under age 18) or a person under the age of 21 (who is under the supervision of your parents), and you engage in behaviors that are seriously threatening your health and well-being, this information may be divulged. I will try to inform you of this decision before I do so.

Angela C. Chapman, M.D. practices with an association of independently practicing professional which share certain expenses and administrative functions under the name Psychology & Counseling Associates, P.A. While they share office space, Angela C. Chapman, M.D. is a completely independent professional rendering clinical services and is fully responsible for those services. Clinical records are separately maintained and other professionals cannot have access to them without your specific written permission.

If you have any questions regarding this policy, please discuss these with me as soon as possible. Your signature indicates consent for psychological/psychiatric treatment and to indicate that you have read the above statement and agree to the above terms. I appreciate your commitment to this process and thank you for your assistance in and understanding of these necessary policies.