Confidentiality and Records Agreement Note (Couple/Family)

(Administrative agreement only; do not include therapy content, symptoms, trauma history, or clinical formulation. If information is unknown or not assessed, state "not assessed.")

Date: [date of discussion]

Clinician: [name and credentials]

Encounter Type: [intake / first conjoint session / update / addendum]

Modality: [in-person / telehealth / phone]

Parties Present & Client Unit Definition

• Client System Members: [List each individual: name, date of birth, relationship role, and present/absent status] (For absent parties, note agreement is pending and specify any interim limits under which services proceeded.)
• Legal Authority & Capacity to Consent: [Adult/minor status, custody/guardianship arrangements, legal authority to consent, interpreter needs, any coercion or voluntariness concerns] (If not assessed, state "not assessed.")
• Client Unit Definition: [couple/family-as-client / individuals-as-clients / mixed] (If mixed, briefly describe. If no agreement reached, state default policy was applied and describe it.)

Confidentiality & Intra-Family Disclosure

[Confirm general confidentiality and standard limits were reviewed, including exceptions for imminent harm, mandated reporting, court orders, consultation/supervision, and billing disclosures.]

• Intra-Family Disclosure Policy: [permission-based / no-secrets / hybrid] (If hybrid, describe category-specific handling.)
• Individual Sessions/Communications: [yes / no / as needed] (Describe how confidentiality applies and any conditions that may prompt disclosure or pause of conjoint work.)
• Explicit Intra-Family Permissions: [List any specific permissions granted, including scope and limits] (If none, state: "No permission granted for intra-family disclosure beyond conjoint session content.")

Records & Outside Disclosures

• Psychotherapy Notes: [maintained separately / not maintained separately] (Describe implications for access requests.)
• Record Access for Couple/Family Records: [Describe authorization requirements, handling of non-requesting member information, and any special provisions for minors]
• Portal Access: [Portal access status for each member; proxy access arrangements if applicable]
• ROI Status: [none / signed today / previously signed / revoked / pending] (If pending, state: "No external disclosures will occur until ROI is executed.")
• Insurance/Billing Acknowledgment: [Acknowledge visibility of claims/EOBs to subscriber, if applicable]

Acknowledgment & Signatures

[Document that each participating adult had the opportunity to ask questions and agreement was reviewed in understandable terms, including interpreter use if applicable.]

Key Decisions Documented

• Client unit definition: [unit / individuals / mixed]
• Intra-family disclosure policy: [permission-based / no-secrets / hybrid]
• Individual session policy: [yes / no / as needed]
• ROI status: [none / signed / pending / revoked]
• Record access rule: [brief description]
• Agreement review trigger: [separation / custody change / new member / other]

Signatures

• [Signature line: adult member name, date]
• [Signature line: adult member name, date]
• [Additional signature lines as needed]
• [Clinician signature and date]

(If any signature is not obtained, document the reason, interim policy applied, and whether services continued. For unsigned agreements, state "not yet agreed" rather than implying consent.)