Informed Consent & Confidentiality Discussion Note (Sports Psychology)

(Administrative record of informed consent and confidentiality discussion for sport/performance psychology settings. Do not include session content or therapeutic process details.)

Date/Time: [date and time of consent/confidentiality discussion]

Location: [clinic / training facility / campus office / virtual]

Modality: [in-person / video / phone]

Provider: [provider name, credentials, role]

Reason for Note: [initial consent discussion / update due to specific change]

Present: [names and roles of all participants]

(If virtual, include the following:)

• Client Physical Location: [city/state at time of session]
• Safety Backup Contact: [name, relationship, phone] (Include if required by practice model.)

Parties, Role, and Scope

Requesting Entity/Referral Source: [name and role of requester; what was requested if third party initiated services]

Client Identification: [full legal name] (Explicitly identify the client; do not imply.)

• Client Arrangement: [athlete as individual client / organization as client for consulting / dual arrangement with separate terms for each] (Specify which applies and outline boundaries.)

(If minor, include the following:)

• Guardian(s): [names, relationships, and legal authority]
• Athlete Assent: [obtained / not obtained] [date]

Role Performed: [mental performance consulting / clinical psychotherapy / assessment / embedded consultant / team education]

Scope Statement: [concise description distinguishing performance services from clinical care; note that if clinical needs emerge beyond scope, referral or revised consent will occur]

• Out of Scope: [statement that this is not emergency services]
• Crisis/Safety Pathway: [how to access urgent/emergency support]
• Embedded Role Clarification: [statement clarifying provider is not coaching staff or selection authority] (Include only if embedded.)

Confidentiality and Information Sharing

General Confidentiality Commitment: [summary of confidentiality promise in plain language]

Limits to Confidentiality Reviewed: [risk of serious harm to self/others / mandated reporting obligations / court orders or subpoenas / contracted organizational disclosures] (Confirm these categories were discussed; do not include statutory citations.)

Practical Privacy Limitations: [visibility of attendance, travel settings, facility adjacency, or other environment-specific limitations] (Include only if applicable to sport setting.)

Staff Communication Plan:

• Anticipated Staff Interface: [yes / no] (If no, state that no staff communications will occur and skip remaining items.)
• Approved Recipients: [roles/titles authorized to receive information]
• May Share Without Additional Authorization: [categories of information permitted under this consent, applying minimum necessary principle]
• Requires Signed Release: [categories of information requiring additional written authorization]
• Athlete Notification of Communications: [will notify / may notify / will not notify] [how and when]
• Inbound Information from Staff: [what staff may share with provider and for what purpose]

Records and Access:

• Record System: [private practice system / organizational EHR / shared sports medicine record]
• Access Within Organization: [roles/titles who may access, or "none"]
• Separate Notes Maintained: [yes / no] (If yes, briefly describe which notes are separate.)
• Record Request Process: [how athlete, guardian if minor, and external parties may request records]

Consent Confirmation

• Consent Method: [written signature / electronic signature / verbal consent] [date]
• Documents Provided: [list document titles]
• Capacity to Consent: [client oriented and able to consent / concerns noted] (For minors, note guardian permission and athlete assent obtained.)
• Opportunity for Questions: [provided; summarize key questions if any]
• Teach-Back: [client's own-words summary of what will and will not be shared] (Required if staff communication is involved.)
• Authorization for Staff Communication: [full / conditional / refused] (Document any specific restrictions requested.)
• If Sharing Refused Where Typically Required: [whether services can proceed and alternatives offered] (Include only if applicable.)
• Ongoing Review Plan: [triggers for revisiting consent: role changes, staff changes, postseason, etc.] [next review date if known]
• Incomplete Elements: [what remains to be completed and timeline] (Include only if consent discussion was partial.)

Provider Signature: [name, credentials] [date]

Consent Forms on File: [titles and dates of signed documents]