SA Client Consent for Clinical Formal Disclosure Please read and initial the following statements if you have discussed with your therapist and agreed to participate in Formal Disclosure; sign and date at the bottom: Please enable JavaScript in your browser to complete this form.Initial *I,Client Name *understand that Formal Disclosure is a part of the standard of care for sex addiction recoveryInitial *I give consent and release to allow my partner or spouse to join me in my clinical session to facilitate Formal Disclosure and post-disclosure meetingsInitial *I agree that my questions and concerns regarding Formal Disclosure have been answered by my therapistInitial *I understand that I am not required to participate in Formal Disclosure if I choose not to do soInitial *I have worked with a professional clinician, one who is licensed and certified to support my process of Formal DisclosureInitial *I have been given materials, prep sheets, instructions, reading recommendations, and a careful process of preparation and support by my therapistInitial *I have the support of a sponsor, 12-step group, and other safe supports in placeInitial *I agree to contact 911, my therapist and other safe supports if I feel I am at risk to myself or another post-disclosureInitial *I agree not to abuse substances or participate in risky self harm behaviors pre or post-disclosure, including sexually acting outInitial *I agree to arrive sober to Formal DisclosureInitial *I agree to take a polygraph as part of Formal Disclosure if my partner/spouse requests thisInitial *I understand the limits of confidentiality (child abuse, downloading producing or watching child pornography, elder abuse, dependent adult abuse) as outlined in my initial client intake and informed consent formsInitial *I understand that should I disclose anything that falls into the limits of confidentiality, my therapist is a mandated reporter and is legally required to disclose this information to the proper authoritiesInitial *I agree to be responsible for any additional fees (this would include adjunct professionals, longer sessions, materials as needed) as part of the Formal Disclosure processInitial *I agree to participate respectfully and to request a time-out if needed during Formal DisclosureInitial *If I am feeling overwhelmed, ill, or faint, I understand that I can ask to stop Formal DisclosureInitial *I agree to drive separately, and if I am feeling as if I may need someone to drive me due to anxiety, I will discuss this with my spouse/partner and we will decide on a safe person to drive meInitial *I agree to continue my therapy and to complete the other parts of Formal Disclosure, including the Emotional Restitution (letter of apology) for my spouse/partner and meetingInitial *I agree to alert my therapist if I am feeling at risk for suicide or homicideInitial *I understand that there is no way for my therapist to predict the outcome post-Formal Disclosure. Possible outcomes may include: separation, divorce, impact on emotional well being, challenging feelings, law suits, public or private exposure, loss of respect and trust by spouseClient Signature *Date *FOR YOUR OWN SAFETY, AND IN ORDER FOR YOUR THERAPIST TO BEST SUPPORT YOU DURING FORMAL DISCLOSURE, PLEASE RETURN THESE FORMS TO YOUR THERAPIST 1-WEEK PRIOR TO YOUR FORMAL DISCLOSURE DATE. FORMAL DISCLOSURE WILL NOT CONTINUE WITHOUT THESE FORMS IN PLACE.Submit