Chicago Wellness Initiative
via TGC
Confidentiality Notice


Limits of Confidentiality 

Information you disclose in therapy sessions are considered to be confidential. Both verbal information and written records about a client cannot be shared with any other party without written consent of the client or the clients legal guardian. 


No Information Collected

Because you are attending a free, confidential counseling session, no personal information about you is collected or stored, outside of this notice of how confidentiality will works for this session, outside of your signature below. 



These initial assessment sessions that do not require registration or personal information, are limited to (2) before you would need to transfer to another provider or registering with our front desk as a client, which will require you to give identifying information about yourself, in the same manner as any visit to a doctor’s office would require. 

Duty to Protect

Should  you disclose intention to hurt yourself or someone else, (suicidality/ homicidality / vulnerable  adult  & child abuse), it is the healthcare professionals duty to intervene. This may include calling 911 to intervene in any action plan  to hurt yourself or someone else.  


Release of Liability

You understand that this visit is not offered as a substitute for medical care and is not intended to  treat or cure any mental health or medical conditions. The purpose of this visit is to get support, resources, beginning coping skills, and to explore the journey the counseling can offer.   I understand and agree that I am fully responsible for my well-being after the visit and that if I am in crisis at any time after this visit ends, I should call 911, or go to my nearest emergency room for help. 


In order to verify that you, ( the actual client), has authentically read this document themselves, asked any questions of the clinician meeting with you now,  understand and agree, please call our special line at:

630-296-4535, and simply leave a voice confirmation.


Here’s a simple and fast script that might aid in “What do I say?”:


 This is __Name__, I have read and agree to, the confidentiality notice given to me at today’s appointment with ___Clinicians name___ , at __Date___.


” This Ralynn Jones, I read and agree to the confidentiality notice that Kaitlin gave me for today’s appointment on July 1st, 2022.