Running head: INFORMED CONSENT 1

Informed Consent

Student’s Name

Institutional Affiliation
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Informed Consent

About the Client

My client’s name is Eliot Smith. Eliot is a 30-year old Japanese-American male. He has

visited the agency seeking treatment for depression. Eliot has a significant history of suicide

attempts and substance abuse. Working this client may not be easy because his cultural values

clash with mine.

Addressing the client

Good morning Eliot, my name is Shekima, and I will be working with you as your

counselor. Let me first congratulate you for visiting our agency to work on your wellness. Before

we begin the process, there is some of your personal information I would like us to look into.

The information will be used for diagnosis, treatment planning, and any referrals to additional

services that may be needed, including medication management.

I take your privacy very seriously. Therefore, I will keep private the personal information

you will share with me. Also, there are laws in place to safeguard your privacy. The Health

Insurance Portability and Accountability Act (HIPPA) have a privacy rule in place that creates

national standards to safeguard your personal information. Therefore, I will ensure that your

records are maintained in a secured electronic medical record on my computer. I will not discuss

or share the information with a third party without your explicit permission. You will be able to

access an electronic or hard copy from our clinical records department.

As I had told you earlier, the information you share with me is private. However, some

circumstances might need me to disclose your personal information. I may share your personal

information with other practitioners for the continuity of your care. Such disclosure would be

necessary for it will provide you with a complete assessment and appropriate treatment. I may
INFORMED CONSENT 3

also disclose your personal information as a part of a defense against disciplinary, criminal, and

civil action.

Now I would like to issue you with an informed consent form, which contains summary

information about your rights as a client. The written consent will be essential for me to talk to

anyone about your treatment. You may decide to revoke your consent at any time. The

revocation need not be in writing. Please be aware of any penalties you may experience by not

complying with their requests.