Suicide and Homicide Disclosure Agreement

By signing this document, you are consenting to services with Nine Lives Counseling Service, as well as indicating you understand your privacy rights when you engage in services.

Professional Disclosure Statement – Suicide and Homicide Disclosure Agreement

Thoughts of suicide and/or homicide can and do arise during times of stress and crisis. While privacy and confidentiality are important in the counseling relationship, the counselor has a responsibility to protect the life and well-being of the client and other people. As such, if a client discloses thoughts of suicide or homicide during a session, they can expect the following to happen: • The client will be treated with the utmost respect and their concerns taken seriously. • The counselor will work with the client to determine the severity of the thoughts of suicide and/or homicide. • The counselor will assess what level of planning the client has taken towards acting on their thoughts of suicide and/or homicide. • The counselor will engage in a collaborative process with the client to safety plan around their thoughts of suicide/homicide, with the intention of disabling any plans. • If an adequate safety plan cannot be agreed upon by the client and counselor, they will work together to determine who else might be brought in to assist. This could include family members, friends, primary care physicians, and/or emergency medical services. • If the client is unwilling or unable to engage in safety planning and is intent on acting on their thoughts of suicide/homicide soon, the counselor may break confidentiality to alert emergency medical services. In addition, if the client has disclosed thoughts of suicide and/or homicide in past sessions, and then does not attend a session without forewarning (“no call, no show”) and the counselor has concerns for the safety of the client, the counselor reserves the right to try to contact the client outside of pre-scheduled session times. If unsuccessful in contacting the client, the counselor will attempt to contact the client’s emergency contact. If that is unsuccessful or if the client cannot be located, and there is a significant concern for the safety of the client and/or other people, emergency services may be contacted. I understand and consent to enter a counseling relationship with Nine Lives Counseling Service and Aiden Rohwer-Nutter. I understand that this will also be discussed with me during the first appointment with the counselor.
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