Client Intake
Confidentiality & Privacy Agreement
Please read this agreement in full before signing. It describes how your information is protected within our coaching and therapeutic practice.
I. Purpose of This Agreement
Confidentiality is the foundation upon which the coaching and therapeutic relationship rests. Meaningful work depends on your ability to speak openly, without fear that what you share will travel beyond the room in which it was spoken. This agreement sets out, in plain terms, the protections extended to you, the narrow circumstances in which the law may require disclosure, and the rights you hold over your own records. It is offered not as a formality, but as a statement of the standard of care to which this practice holds itself.
II. Our Commitment to Confidentiality
All information you share — whether verbally, in writing, electronically, or through any assessment, intake questionnaire, session note, recording, correspondence, or other communication — is held in strict confidence. Your information will never be sold, traded, rented, published, used in marketing or case study material, or disclosed to any third party, including family members, employers, colleagues, or other practitioners, without your explicit written consent, except in the limited circumstances outlined in Section IV below. This commitment extends to the fact of your participation itself: we will not confirm to any third party that you are, have been, or have inquired about becoming a client. Any consent you provide may be withdrawn by you in writing at any time, and that withdrawal takes effect immediately with respect to any disclosure not yet made.
III. Protected Health Information & Privacy Practices
Protected information includes your name, contact details, date of birth, home address, health and wellness history, the content of our sessions, any notes or assessments arising from them, and your payment and billing information. All such records are stored in encrypted, access-controlled systems, with transmission secured in transit and at rest. Access is limited to the practitioner and, where applicable, a clinical supervisor bound by equivalent confidentiality obligations. No administrative, technical, or third-party personnel are granted access to session content.
In plain English, you have the right to:
- Request access to, and a copy of, your own records.
- Request that inaccurate or incomplete information be corrected.
- Request a restriction on how your information is used or disclosed.
- Request an accounting of any disclosures that have been made.
- File a complaint, without retaliation, if you believe your privacy has been violated.
IV. Limits to Confidentiality
There are narrow circumstances in which disclosure may be required or permitted by law without your consent. Where disclosure becomes necessary, only the minimum information required will be released, and you will be informed wherever it is safe and lawful to do so. These circumstances are:
- Where there is an imminent risk of serious harm to yourself or to another identifiable person.
- Where abuse or neglect of a child, an elder, or a dependent adult is suspected.
- Where a valid court order or legal subpoena compels disclosure.
- Where disclosure is required for billing or insurance processing, if applicable to your arrangement.
- Where professional supervision or consultation is undertaken with a party bound by equivalent confidentiality obligations.
- In a medical emergency, where information is necessary to protect your health or safety.
V. Electronic Communication & Telehealth
Email, text messaging, and video-session platforms carry inherent security limitations that no provider can entirely eliminate. Messages may be intercepted, misdirected, retained by a service provider, or viewed on a shared or unsecured device. Reasonable safeguards are used — encrypted platforms, access controls, and restraint in the detail shared over such channels — but absolute security cannot be guaranteed. By choosing to communicate electronically or to attend remote sessions, you accept these limitations in exchange for the convenience of remote communication, and you may ask at any time to move our correspondence to a different channel.
VI. Record Retention & Destruction
Client records are retained for a minimum of seven (7) years, or as required by applicable state law, whichever period is longer. Where the client is a minor, retention periods are calculated from the date the client reaches the age of majority. At the end of the retention period, records are securely and permanently destroyed — paper records by cross-cut shredding, and electronic records by irreversible deletion from all active systems and backups.
VII. Minors
If the client is under eighteen (18) years of age, a parent or legal guardian must review this agreement in full and countersign it before services begin. Where appropriate, the scope of information shared with a parent or guardian will be discussed openly with the young person at the outset.
This agreement is provided as a general practice template and does not constitute legal advice. Please have it reviewed by a licensed attorney familiar with the applicable state and federal requirements (including HIPAA, if applicable to your practice) before use.
CLIONA O'HARA COACHING
646-391-3003 · cohara@napoleonhillinstitute.com